Ph Levels Too High

A common alkaline urine pH, might be a condition of hypokalemia or even a renal tubular acidosis in which the kidneys fail to get rid of it the acid into the urine resulting in acid blood. This will result in lack of bicarbonates in the blood too.

Frequently the hospital treatment for hypokalemia is sodium bicarbonate, potassium chloride, and some antibiotics.

For me I prefer sodium bicarbonate plus potassium citrate (1/2 teaspoon of baking soda plus 1/4 teaspoon of potassium citrate in 1/2 glass of water taken twice a day) and some 1/4 teaspoon sea salt added to the one liter drinking water as a weak form of antibiotics with some 10 drops of 3% H2O2.

It may be the HPV virus that is causing this problem resulting in the hypokalemia and hence 50 mg of zinc gluconate may be taken once every other day for the first week with resulting once a week zinc gluconate as a more natural form of antibiotics against the HPV virus. Furthermore to protect the kidneys some vitamin D3 or D4 10,000 i.u. once a week might be helpful or if unavailable cod liver oil one teaspoon a day for 5 days out of a week with some gradual reduction in the remedy of cod liver oil as it is high in vitamin D also.

As evidence of alkaline urine, the following links I posted below. The research posted below mentions the following:

"In both the cases, the patients had muscular hypotonia, hypokalemia, decreased blood bicarbonates, decreased blood pH, and alkaline urine. Therefore both were diagnosed as cases of distal renal tubular acidosis. In most diseases, hypokalemia is associated with metabolic alkalosis, but in renal tubular acidosis metabolic acidosis is seen."

And their remedy and recommendation which is close to my original remedy is:

"These patients need intravenous sodium bicarbonate therapy. Use of oral or intravenous potassium alone will mot ameliorate the condition."

Therefore the remedy stays the same even if the urine pH is alkaline for at least the condition of hypokalemia. It seems certain virus or bacteria is one of the cause too, besides just the baking soda and the potassium. Of course I am assuming hypokalemia because of the lack of information you posted but it could be other causes. The other causes is ammonia urine, but unlikely since this is not mentioned here.

Ted

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijtm/vol3n1/acidosis.xml

The Internet Journal of Tropical Medicine TM ISSN: 1540-2681

Home | Current Issue | Archives | Instructions for Authors | Disclaimer | Printable Version Renal Tubular Acidosis Presenting As Severe Hypokalemia With Respiratory Paralysis: Report Of Two Cases

Indira Mishra Ispat General Hospital Rourkela India

Saroj K. Mishra Ispat General Hospital Rourkela India

Sudhansu S. Pati Ispat General Hospital Rourkela India

Devendra N. Mohapatra Ispat General Hospital Rourkela India Citation:

Indira Mishra, Saroj K. Mishra, Sudhansu S. Pati, Devendra N. Mohapatra: Renal Tubular Acidosis Presenting As Severe Hypokalemia With Respiratory Paralysis: Report Of Two Cases. The Internet Journal of Tropical Medicine. 2006. Volume 3 Number 1. Keywords: Renal tubular acidosis, respiratory distress, hypokalemia

Table of Contents

Abstract Introduction Case 1 Case 2 Discussion References Abstract Hypokalemia is usually asymptomatic and goes undetected. Or it may manifest as muscular weakness, fatigue, abdominal distension. Severe hypokalemia may lead to cardiac arrhythmias and even death. However, respiratory paralysis leading to hypoventilation and respiratory failure is uncommon and very rarely reported in the literature. We report two patients of hypokalemia with quadriplegia who developed respiratory paralysis and cyanosis, requiring ventilatory support. Both were diagnosed as cases of renal tubular acidosis.

Introduction

Hypokalemia is a common electrolyte disturbance encountered in clinical practice. Common clinical conditions in which hypokalemia is found are diarrhea, vomiting, hopokalemic periodic palsy, overuse of diuretics, diabetic ketoacidosis etc. Clinically, hypokalemia presents with muscular weakness, fatigue , abdominal distension. Severe hypokalemia may lead to and cardiac arrhythmias and even death. However, respiratory paralysis leading to hypoventilation and respiratory failure is uncommon and very rarely reported in the literature 1 , 2 , 3 , 4 . These are associated commonly with renal tubular acidosis 1 , 2 , 3 or Sjogren syndrome 2 .

We report two such cases of hypokalemia who developed respiratory paralysis and required ventilatory support. Case 1

An eight year old girl presented with weakness of all four limbs for three days. She developed breathing difficulty and was brought to the hospital. She had no history of vomiting, diarrhea, or fever . She was not a diabetic nor any history of drug or diuretic use. There was no family history suggestive of endocrine disorders or metabolic disorders. Mile stones of development were normal. At the time of admission, she was drowsy, dehydrated, tachypnoeic with respiration rate of 40 / minute. Heart rate was 100 bpm,. BP: 110/70 mm of Hg. There were no abnormal signs in lungs and heart. Neurological examination showed decreased power in all four limbs (Grade - II/V). Limb muscles were flaccid, deep tendon jerks were diminished. She was cyanosed in spite of high flow oxygen therapy by mask as well as nasal prongs. Her sensorium started deteriorating. She was therefore put on ventilator.

Investigations: Hb 10g/dl, Serum K+ 2.1 mEq/l, Na+ 137 mEq/l, pH 7.18 bicarbonate 8.5meq/l , Chloride 129 mEq/l , PaCO2 23.6 mm of Hg, PaO2 : 74 .U waves were seen in E C G. Urine pH was 7.2, urine calcium 125mg per twenty four hours and potassium was 27 meq /l. Trans tubular potassium concentration gradient (TTKG) was 4.6. Ultrasound KUB showed bilateral nephrocalcinosis. She improved over... days and was weaned from the ventilator. She was discharged from the hospital on... days. She was admitted once more to the hospital in subsequent years, but made a prompt recovery on appropriate management with sodium bicarbonate.

Figure 1: Ultrasonography showing Nephrocalcinosis (Case-1)

Case 2

A thirty eight year old woman presented with progressive weakness of limbs for four days and breathing difficulty for five-six hours . She was treated elsewhere with potassium chloride with the provisional diagnosis of hypokalemic periodic paralysis .On examination she was dyspnoeic with a respiration rate of 32/min, heart and lungs showed no abnormality.

Neurological examination revealed diminished power in both upper and lower limbs ( Gr II-III/ V), and diminished deep tendon jerks .There was hypokalemia (2.8meq/l), blood pH 7.21, HCO3 :11.7meq/l and PaCO2 27 mm of Hg. Urine pH was 7.1 and potassium 31meq /l . ECG showed U waves in V2 to V5 with T inversion . TTKG was 4.2 . Oxygen saturation was 80% . She required ventilatory support for 48 hours.

Both the patients recovered completely with Inj. sodium bicarbonate, intravenous potassium, antibiotics and ventilatory support. There was no evidence of Sjogren's disease in any of them. Discussion

Mild hypokalemia is invariably clinically insignificant and goes undetected. However, significant hypokalemia can cause weakness, and cardiac arrhythmia. They respond to treatment with potassium supplementation either orally or intravenously. However, respiratory distress amounting to cyanosis is very unusual.

Gambar et al 1 from India reported a case of 26 year old lady with hypokalaemic quadriplegia, acute respiratory failure and life-threatening cardiac arrhythmias. She was diagnosed as a case of distal renal tubular acidosis. She had persistent metabolic acidosis with severe hypokalaemia and required mechanical ventilation and potassium replacement.

Poux et al 2 from France described a 38 year woman with hypokalemic flaccid quadriplegia with sudden respiratory arrest. The woman was found to have distal renal tubular acidosis which lead to the diagnosis of primary Sjogren's syndrome. This case was compared to 8 similar cases previously described in the literature till 1992.

Haddad S et al 3 from S Arabia a 33-year-old female patient admitted to the ICU with ascending muscle weakness leading to acute hypercapneic respiratory failure following 10-day history of severe diarrhea and vomiting. Investigations revealed severe hypokalemia, mixed metabolic and respiratory acidosis, and renal impairment.

Le Corre A et al 4 from France described an unusual cause of acute respiratory distress in 2000. in a 54-year-old patient was admitted for ketoacidosis with acute respiratory distress. The main and unusual cause of being hypophosphataemia. Correction of the metabolic acidosis by insulin therapy resulted in intracellular penetration of phosphate and potassium, causing severe hypophosphataemia and hypokaliaemia responsible for Acute respiratory distress.

In our hospital, though we encounter several cases of periodic paralysis due to hypokalemia we suspected these cases to be different and probed for possibility of other etiology.

In both the cases, the patients had muscular hypotonia, hypokalemia, decreased blood bicarbonates, decreased blood pH, and alkaline urine. Therefore both were diagnosed as cases of distal renal tubular acidosis. In most diseases, hypokalemia is associated with metabolic alkalosis, but in renal tubular acidosis metabolic acidosis is seen.

Renal tubular acidosis is a disorder of renal tubules having normal anion gap (hyperchloremic ) metabolic acidosis in the presence of normal glomerular function. In distal RTA there is deficiency of H+ ion secretion in distal tubules and collecting ducts. This can manifest as gradient limited defect where urine pH is always greater than 5.5 .

The kidney does not lower the urine pH either because the collecting permits excessive back diffusion of H ion from lumen to blood or because they fail to transport H ion against a steep pH gradient.

Chronic acidosis lowers tubular reabsorption of calcium causing renal tubular hypercalciuria. The hypercalciuria, alkaline urine and low level of urine citrate cause calcium phosphate stones and nephrocalcinosis. This was observed in our first patient. The stunted growth in this case may be due to acidosis induced loss of bone minerals and inadequate production of 1,25 dihydroxycholecalciferol. In both children and in adults, since the kidney does not conserve potassium, hypokalemia occurs with the stress of an intercurrent illness. Acidosis and hypokalemia can be life threatening which was observed in both these cases.

These patients need intravenous sodium bicarbonate therapy. Use of oral or intravenous potassium alone will mot ameliorate the condition. Address for correspondence

Dr SK Mishra, MD Joint Director & Head Dept of Internal Medicine, Ispat General Hospital, Rourkela -769005, INDIA Email: [email protected] References

1. Gombar S, Mathew PJ, Gombar KK, D'Cruz S, Goyal G. Acute respiratory failure due to hypokalaemic muscular paralysis from renal tubular acidosis. Anaesth Intensive Care. 2005 ;33:656-8.

2. Poux JM, Peyronnet P, Le Meur Y, Favereau JP, Charmes JP, Leroux-Robert C. Hypokalemic quadriplegia and respiratory arrest revealing primary Sjogren's syndrome. Clin Nephrol 1992 ;37:189-91.

3. Haddad S, Arabi Y, Shimemeri AA. Hypokalemic paralysis mimicking Guillain-Barre syndrome and causing acute respiratory failure. Middle East J Anesthesiol. 2004;17:891-7.

4. Le Corre A, Veber B, Dureuil B.An unusual cause of acute respiratory distress Ann Fr Anesth Reanim. 2000;19: 549-51