The Curbsiders Internal Medicine Podcast

#308 Metabolic Alkalosis and Hypokalemia: Kidney Boy Returns!

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Nov 29, 2021
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ADVICE

Give Normal Saline For Chloride-Responsive Alkalosis

  • Use normal saline (0.9% NaCl) to resuscitate metabolic alkalosis from vomiting or chloride loss.
  • Give chloride-rich fluids because these patients are chloride-starved and need sodium chloride to correct alkalosis.
INSIGHT

Generation Versus Maintenance Of Alkalosis

  • Metabolic alkalosis has two phases: generation (loss/addition of acid/alkali) and maintenance (things that force the kidney to reabsorb bicarbonate).
  • Common maintenance mechanisms are kidney failure and volume/chloride deficiency, which keep bicarbonate reabsorbed despite the initial insult.
INSIGHT

Why Low Potassium And Aldosterone Sustain Alkalosis

  • Hypokalemia helps maintain metabolic alkalosis by causing intracellular H+ shift and apparent intracellular acidosis that stimulates renal bicarbonate retention.
  • High aldosterone activity (from volume depletion or primary causes) also drives hydrogen loss and bicarbonate reabsorption.
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