The Cribsiders S7 Ep150: NepHron Nuances: Approach to Diagnosing and Treating RTAs
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Aug 27, 2025 Dr. Michelle Starr, a pediatric nephrologist at Indiana University, dives into the intricacies of renal tubular acidosis (RTA). She discusses distinguishing between RTA types and shares vital diagnostic clues specific to pediatric care. The conversation covers the impact of high-chloride IV fluids, urine gap measurements, and the significance of electrolyte levels in treatment. With clinical anecdotes and case studies, Dr. Starr emphasizes the importance of collaboration with nephrologists for effective management of RTA in children, enhancing understanding of acid-base balance.
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Confirm Acidosis And Check The Gap
- Confirm metabolic acidosis with pH, PCO2, and bicarbonate before labeling RTA.
- Calculate anion gap to separate anion-gap from non-anion-gap causes first.
Rule Out GI Losses And Chloride First
- In non–anion-gap metabolic acidosis, prioritize GI bicarbonate losses and iatrogenic chloride before RTA.
- Look for diarrhea, surgical drains, or large normal saline exposure as common causes.
Kidney Roles In Bicarbonate Handling
- Kidneys reclaim most filtered bicarbonate in the proximal tubule and must resynthesize bicarbonate distally.
- Children have higher distal bicarbonate needs per kg than adults.