Patterns of metabolic acidosis in patients with chronic renal failure: impact of hemodialysis

The type of metabolic acidosis in patients with chronic renal failure was studied prospectively over a three-month period in 32 stable patients on chronic hemodialysis using acetate. All patients had pre-dialysis metabolic acidosis (mean TCO2 = 16.6 +/- 0.4 mEq/l, range 10 to 23 mEq/l). The patterns of metabolic acidosis were defined using the ratio: delta AG/delta TCO2 where delta AG is the increment in plasma anion gap above normal and delta TCO2 the decrement in plasma bicarbonate below normal. The group as a whole showed a mixed hyperchloremic and high anion gap pattern with a mean delta AG/delta TCO2 ratio of 53.3 +/- 7.1%. The individual distribution of patterns ranged from a pure hyperchloremic acidosis (24%) to a pure high anion gap acidosis (30%) with the mixed pattern being the most frequent (46%). An inverse correlation between the TCO2 change (y) during the dialysis procedure and the TCO2 (x) prevailing at the start of dialysis was found by linear regression analysis: y = -0.51x + 11, r = -0.54, p less than 0.01. Thus, before acetate conversion to bicarbonate was fully completed, patients gained bicarbonate during dialysis if TCO2 was less than 21 mEq/l and lost it when the pre-dialysis TCO2 was above this level. On average, the delta AG was reduced to a greater extent than the delta TCO2 so that the delta AG/delta TCO2 ratio fell significantly (from 53 +/- 7.1 to 11 +/- 8.8%, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Uptake of Br in mitochondria-rich and principal cells of toad skin epithelium

To elucidate the route of transepithelial Cl transport across amphibian skins, electrolyte concentrations and uptake of Br in different epithelial cell types of toad skin were determined using electron microprobe analysis. Under short-circuited conditions, Cl concentrations were about 10 mmol/kg ww lower in MR-cells (23.9±9.6 mmol/kg ww) than in principal cells and showed a large scatter. After unitateral substitution of Br for Cl in the bathing solutions, principal cells exchanged Br for Cl only from the serosal side, whereas variable amounts of Br were gained in MR-cells from either side. The ratio of Br to Cl concentrations in MR-cells averaged 0.35 and 0.81 after incubation with NaBr-Ringer's on the apical or serosal side, respectively. After activation of transepithelial anion conductance by serosa-positive voltage-clamping to 100 mV, uptake of Br from the apical side was increased in MR-cells compared with short-circuited conditions. On the average, the ratio of cellular Br to Cl concentrations was 1.38, but the variation among individual MR-cells from the same tissue was considerable. In MR-cells with large uptake of Br and voltageactivated conditions, the sum of Br and Cl concentrations was higher than the Cl concentration under control conditions. The increase of anion content was associated by increase of the Na and corresponding decrease of the K concentrations. The MR-cells were swollen as indicated by the decrease in the cellular dry weight content from 22.2±2.5 to 17.1±4.2 g/100 g. The principal cells contained 3.5±2.6 mmol/kg ww Br after voltage activation of anion conductance which appears to be taken up from the lateral intercellular spaces across the basolateral membrane.The data indicate that principal cells are not involved in transepithelial Cl transport. The MR-cells, although representing a heterogeneous cell population, might be a site for electrodiffusional transepithelial Cl movement.Dedicated to Prof. Dr. med. Dr. h.c. Klaus Thurau on the occasion of his 60th birthday     

Changes in the plasma anion gap during chronic metabolic acid-base disturbances.

A basic premise in the utilization of the plasma anion gap in the assessment of acid-base disorders is that this parameter remains constant during hyperchloremic metabolic acidosis and metabolic alkalosis. Experimental data under in vitro conditions, however, cast serious doubt on this premise. The purpose of the present study was to characterize the plasma anion gap, estimated as (Na + K) - Cl + HCO3), in two large groups of dogs with graded degrees of chronic, HCl-induced metabolic acidosis or chronic, diuretic-induced metabolic alkalosis. The data indicate that the plasma anion gap decreases significantly in HCl acidosis and increases significantly in metabolic alkalosis; the predicted mean anion gap in animals with a plasma bicarbonate concentration of 10, 21 (normal), and 40 meq/liter approximated 13, 18, and 26 meq/liter, respectively. The observed variation in the plasma anion gap is interpreted as originating mainly from directional changes in the net negative charge of plasma proteins; these changes result from the titration process secondary to the altered plasma acidity and, in the case of metabolic alkalosis, from the additional effect of an increased plasma protein concentration.     

Statin precipitated lactic acidosis?

An 82 year old woman was admitted with worsening dyspnoea. Arterial blood gases were taken on air and revealed a pH of 7.39, with a partial pressure of CO2 (pCO2) of 1.2 kPa, pO2 of 19.3 kPa, HCO3 of 13.8 mmol/litre, and base excess of -16.3 mmol/litre: a compensated metabolic acidosis with hyperventilation induced hypocapnia, which is known to be a feature of lactic acidosis. There was also an increased anion gap ((Na140 + K4.0) - (Cl 106 + HCO3 13.8) = 24.2 mEq/litre (reference range, 7-16)), consistent with unmeasured cation. Lactate was measured and found to be raised at 3.33 mmol/litre (reference range, 0.9-1.7). After exclusion of common causes of lactic acidosis Atorvastatin was stopped and her acid-base balance returned to normal. Subsequently, thiamine was also shown to be deficient. The acidosis was thought to have been the result of a mitochondrial defect caused by a deficiency of two cofactors, namely: ubiquinone (as a result of inhibition by statin) and thiamine (as a result of dietary deficiency).     

Recovery of cell volume and electrolytes of A6 cells after re-establishing isotonicity following hypotonic stress

Cellular element concentrations and dry weight contents in A6 cells were determined using electron microprobe analysis to establish whether these cells exhibit a regulatory volume increase (post-RVD-RVI) when re-establishing isotonicity following a hypotonically induced regulatory volume decrease (RVD). Hypotonic stress was induced by reducing basolateral [NaCl], and hence, osmolarity fell from 260 to 140 mosmol/l. The alterations in cell volume after re-establishing isotonicity, calculated from the cellular dry weight changes, indicate within the first 2 min cell shrinkage from 120 to 76% of control, compatible with almost ideal osmometric behaviour of A6 cells, and thereafter a post-RVD-RVI to 94%. The cellular uptake of osmolytes necessary to explain the post-RVD-RVI could be accounted for solely by a gain in cellular K and Cl. The involvement of a Na-K-2Cl cotransporter in most of the KCl uptake seems plausible since basolateral bumetanide blocked KCl uptake and post-RVD-RVI. The net uptake of cations (K uptake of 185.2, Na loss of 8.2 mmol/kg dry wt) during the isotonic period exceeded the Cl uptake by 38.2 mmol/kg dry wt, suggesting the uptake of another anion and/or the alteration of cellular buffer capacity. The relatively low Na concentration maintained during the isotonic period (13.3 vs. 20.4 mmol/kg wet wt under control conditions) might favour electrolyte uptake via the Na-K-2Cl cotransporter.     

Variations according to age and gender for creatinine clearance estimated with the Cockroft and Gault formula in a selected population of ambulatory adults

The distribution and variations according to age and gender for the creatinine clearance calculated by the Cockcroft and Gault formula (Cl C-G) were determined thanks to a case-control study on a population of selected adults with a plasma creatinine concentration < 137 micromol/L (man) or < 104 micromol/L (woman) and a plasma urea concentration < 8.3 mmol/L. 286 men and 270 women aged between 18 and 80 were considered. The frequency distributions for creatinine (dosed by a kinetic Jaffe method ) and Cl C-G are Gaussian (p < 0.01; Kolmogorov-Smirnov test). Cl C-G diminishes with age (r = 0.73; p < 0.001), average: 10 mL/min/decade (man) and 11 mL/min/decade (woman). No significant relation could be found between the weight/creatininaemia ratio and age. Cl C-G is weaker for women: 11 to 18 mL/min according to age. 53% of women older than 70 years have an estimated glomerular filtration rate below 60 mL/min. The 2.5th centiles for Cl C-G values vary, for man: from 105 mL/min (confidence interval 95%: 100-110 mL/min) between 18 and 30 years old, to 53 mL/min (49-57) between 71 and 80 years old; for woman: from 85 mL/min (80-90) between 18 and 30 years old to 42 mL/min (38-46) between 71 and 80 years old. With such results, the correcting factor related to Cockcroft and Gault's formula gender seems to be insufficient. New reference values and limits of decision of Cl C-G must be determined for each analytical method.     

Acid-base balance in combined severe hepatic and renal failure: a quantitative analysis

BACKGROUND: Severe hepatic failure (SHF) commonly leads to major changes in acidbase balance status. However, the direct effects of liver failure per se on acid base balance are poorly understood because this condition is usually associated with acute renal failure (ARF). AIM: To assess the effect of SHF on acid-base balance. DESIGN: Retrospective laboratory investigation. SUBJECTS: Thirty-seven critically ill patients with SHF complicated by ARF, and 42 patients with severe ARF without liver failure prior to renal replacement therapy. INTERVENTION: Retrieval of clinical and laboratory data from prospective unit and laboratory databases. METHODS: Quantitative acid-base assessment using Stewart-Figge methodology. Comparison of findings between the two groups. Comparison of demographic and clinical features. RESULTS: Patients with combined SHF and ARF were younger and had significantly higher mean bilirubin, ALT and INR levels (p<0.0001). Their mean lactate concentration was higher (6.4 vs. 2.1 mmol/L; p<0.0001) leading to a greater anion gap (25.8 vs. 16.1 mmol/L; p<0.0001). The ionized calcium concentration (1.00 vs. 1.15 mmol/L; p<0.0001) was lower but the strong ion difference apparent (SIDa) was greater (42.0 vs. 38.0 mEq/L; p<0.005) due to hypochloremia. The albumin concentration was low but higher than in control patients (28 vs. 24 g/L; p<0.01) and the calculated strong ion gap (SIG) was greater (12.6 vs. 9.3 mEq/L; p<0.01). The base excess was similar to controls and the pH was preserved in the near normal range by marked hypocapnea. CONCLUSIONS: Combined SHF and ARF is a syndrome with unique acid-base changes due mostly to lactic metabolic acidosis and, in smaller part, to the accumulation of unmeasured anions. This acidosis, like that of ARF, is attenuated by hypoalbuminemia, by a unique preservation of the SIDa due to hypochloremia, and by marked hypocapnea.     

The use of the urinary anion gap in the diagnosis of hyperchloremic metabolic acidosis

We evaluated the use of the urinary anion gap (sodium plus potassium minus chloride) in assessing hyperchloremic metabolic acidosis in 38 patients with altered distal urinary acidification and in 8 patients with diarrhea. In seven normal subjects given ammonium chloride for three days, the anion gap was negative (-27 +/- 9.8 mmol per liter) and the urinary pH under 5.3 (4.9 +/- 0.03). In the eight patients with diarrhea the anion gap was also negative (-20 +/- 5.7 mmol per liter), even though the urinary pH was above 5.3 (5.64 +/- 0.14). In contrast, the anion gap was positive in all patients with altered urinary acidification, who were classified as having classic renal tubular acidosis (23 +/- 4.1 mmol per liter, 11 patients), hyperkalemic distal renal tubular acidosis (30 +/- 4.2, 12 patients), or selective aldosterone deficiency (39 +/- 4.2, 15 patients). When the data on all subjects studied were pooled, a negative correlation was found between the urinary ammonium level and the urinary anion gap. We conclude that the use of the urinary anion gap, as a rough index of urinary ammonium, may be helpful in the initial evaluation of hyperchloremic metabolic acidosis. A negative anion gap suggests gastrointestinal loss of bicarbonate, whereas a positive anion gap suggests the presence of altered distal urinary acidification.     

Effect of external magnesium on intracellular free sodium: Na+ flux via Na+/Mg2+ antiport is masked by other Na+ transport systems in rat cardiac myocytes.

Mg2+ efflux from heart cells on a Na+/Mg2+ antiport has been postulated, but the Na+ flux component of the antiport has not been demonstrated. The study aimed to establish if the Na+ flux component could be measured by following changes in [Na+]i with SBFI during conditions known to reverse the antiport (5 mmol/L Mg2+(o), Na+(o)- & Ca2+(o)-free): and after minimising the activity of other Na+ transport pathways. Resting [Na+]i was 8 +/- 0.7 mmol/L (mean +/- S.E., n = 39 cells) in normal Tyrode's solution. [Na+]i decreased below the normal level in all cells (a decline of 4-5 mmol/L, n = 21) during perfusion with 5 mmol/L Mg2+(o) (Na+(o)- & Ca2+(o)-free). Controls using 1 mmol/L Mg2+(o) showed similar declines in [Na+]i, but the fall was greatest when Na+(o) was replaced by K+(o) (decline of 6 mmol/L) rather than the tetramethylammonium ion (TMA+). The rate of decrease in [Na+]i during perfusion with 5 mmol/L Mg2+(o) (Na+(o)- & Ca2+(o)-free) was slowed by 20 microM ouabain (n = 5) or by elevation of pHo to pH 9 (n = 7) so that [Na+]i remained close to the initial value. The decrease of [Na+]i was not affected by 10 microM imipramine (n = 15). These data suggest that the Na+ efflux component of the Na+/Mg2+ antiport is masked in Na+(o)- and Ca2+(o)-free conditions by other Na+(i) efflux pathways.     

A case of alcohol-induced ketoacidosis?

We report a case of severe ketoacidosis. Initially the patient showed metabolic acidosis, the anion gap was positive and there was neither hyperlactatemia nor intoxication with acid substances. As the rate of glycemia was high (17.8 mmol/L), the diagnosis of diabetic ketoacidosis was proposed. Under treatment with continuous IV injection of insulin, hypoglycemia (1.8 mmol/L) appeared rapidly, while urine bioreactive test was positive for ketonuria, but negative for glycosuria. We finally concluded that it was an alcoholic ketoacidosis. The history of the patient confirmed the diagnosis : chronic alcoholism with recent increased of alcohol intake which provoked vomiting and fasting. This case report shows the difficulty in distinguishing between alcoholic ketoacidosis and diabetic ketoacidosis. We discuss the diagnostic strategy and particularly biologic data in the light of pathophysiologic mechanism of alcoholic ketoacidosis.     

Regulation of the Na+2Cl–K+ cotransporter in isolated rat colon crypts

The Na(+2)Cl(-)K+ cotransporter accepts NH4+ at its K+-binding site. Therefore, the rate of cytosolic acidification after NH4+ addition to the bath (20 mmol/l) measured by BCECF fluorescence can be used to quantify the rate of this cotransporter. In isolated colon crypts of rat distal colon (RCC) addition of NH4+ led to an initial alkalinization, corresponding to NH3 uptake. This was followed by an acidification, corresponding to NH4+ uptake. The rate of this uptake was quantified by exponential curve fitting and is given in arbitrary units (delta fluorescence ratio units/1000 s). In pilot experiments it was shown that the pH signal caused by the Na(+)2Cl(-)K+ co-transporter could be amplified if the experiments were carried out in the presence of bath Ba2+ to inhibit NH4+ uptake via K+ channels. Therefore all subsequent experiments were performed in the presence of 1 mmol/l Ba2+. In the absence of any secretagogue, preincubation of RCC in a low-Cl- solution (4 mmol/l) for 10 min enhanced the uptake rate significantly from 1.70+/-0.11 to 2.54+/-0.27 U/1000 s (n=20). The addition of 100 mmol/l mannitol (hypertonic solution) enhanced the rate significantly from 1.93+/-0.17 to 2.84+/-0.43 U/1000 s (n=5). Stimulation of NaCl secretion by a solution containing 100 micromol/l carbachol (CCH) led to a small but significant increase in NH4+ uptake rate from 2.06+/-0.34 to 2.40+/-0.30 U/1000 s (n= 11). The increase in uptake rate observed with stimulation of the cAMP pathway by isobutylmethylxanthine (IBMX) and forskolin (100 micromol/l and 5 micromol/l, respectively) was from 2.39+/-0.24 to 3.06+/-0.36 U/1000 s (n=24). Whatever the mechanism used to increase the NH4+ uptake rate, azosemide (500 micromol/l) always reduced this rate to control values. Hence three manoeuvres enhanced loop-diuretic-inhibitable uptake rates of the Na(+)2Cl(-)K+ cotransporter: (1) lowering of cytosolic Cl- concentration; (2) cell shrinkage; (3) activation of NaCl secretion by carbachol and (4) activation of NaCl secretion by cAMP. The common denominator of all four activation pathways may be a transient fall in cell volume.     

Detection of preanalytic laboratory testing errors using a statistically guided protocol

Preanalytic laboratory testing errors are often difficult to identify. We demonstrate how laboratories can integrate statistical models with clinical judgment to develop protocols for preanalytic error detection. Specifically, we developed a protocol to identify spuriously elevated glucose values resulting from improper "line draws" or related phlebotomy errors. Using a decision tree-generating algorithm and an annotated set of training data, we generated decision trees to classify critically elevated glucose results as "real" or "spurious" based on available laboratory parameters. Decision trees revealed that a 30-day patient-specific average glucose concentration lower than 186.3 mg/dL (10.3 mmol/L), a current glucose concentration higher than 663 mg/dL (37 mmol/L), and an anion gap lower than 16.5 mEq/L (16.5 mmol/L) suggested a spurious result. We then used the results from the decision tree analysis to inform the implementation of a clinical protocol that significantly improved the laboratory's identification of spurious results. Similar approaches may be useful in developing protocols to identify other errors or to assist in clinical interpretation of results.     

Serum Biochemistry of Persian Fallow Deer (Dama Mesopotamica)

In order to study serum biochemistry of Persian fallow deer (Dama mesopotamica), sampling was conducted from eight clinicaly normal Persian fallow deer (three females and five males) aged between 6 months and 10 years and the following results were obtained: total protein 68.4 t 5 g/l; albumin 28.1 t 8.9 g/l; globulin 42.7 t 7.5 g/l; A: G 0.63 t 0.25; glucose 6.61 t 3.41 mmol/l; triglyceride 0.37 t 0.22 mmol/l; cholesterol 2.86 t 1.46 mmol/l; blood urea nitrogen 8.91 t 1.21 mmol/l; creatinin 146.75 t 53.92 mmol/l; total bilirubin 12.99 t 2.05 mmol/l; direct bilirubin 7.01 t 1.88 mmol/l; aspartate aminotransferase (AST) 20.25 t 7.36 IU/l; alanine aminotransferase (ALT) 26.38 t 8.94 IU/l; alkaline phosphatase (AP) 118.25 t 70.79 IU/l; creatine kinase (CK) 219.13 t 151.81 IU/l; Na 147.5 t 9.09 mmol/l; K 6.82 t 1.92 mmol/l; Cl 103.88 t 5.44 mmol/l; Ca 2.79 t 0.43 mmol/l; P 1.99 t0.47 mmol/l; Mg 1.12 t 0.23 mmol/l. Significant differences were seen for Na and P between age groups, with higher levels in deer aged less than 2 years (p<0.05). Glucose had higher values in does than in stags (p<0.05). Correlations between measured parameters were also determined.     

Intracellular Na concentration and Rb uptake in proximal convoluted tubule cells and abundance of Na/K-ATPase alpha1-subunit in NHE3-/- mice

Proximal solute and fluid absorption is greatly reduced in mice in which the gene encoding the Na/H exchanger isoform 3 has been ablated (NHE3-/-). To obtain information on the intracellular functional consequences of such selective NHE3 deficiency, Na, Cl and K concentrations and cell Rb uptake were measured using electron microprobe analysis after a 30-s infusion of Rb (an index of basolateral Na/K-ATPase activity) in proximal convoluted tubule (PCT) cells of NHE3-/- and wild-type (NHE3+/+) mice. In addition, the relative abundance of the alpha1-subunit of the Na/K-ATPase in the outer cortex was determined by Western blot analysis. PCT cell Na concentration in NHE3-/- mice was slightly but significantly lower than in NHE3+/+ [13.1+/-0.6 ( n=64) vs. 14.9+/-0.6 ( n=62) mmol/kg wet wt.; means +/-SEM]. The lower intracellular Na concentration was associated with significantly reduced Rb uptake rates [9.7+/-0.6 ( n=59) vs. 14.8+/-0.8 ( n=50) mmol/kg wet wt./30 s], but the abundance of the alpha1-subunit of the Na/K-ATPase was not different between NHE3-/- and NHE3+/+ mice. Intracellular Cl concentration was higher (14.2+/-0.4 vs. 12.8+/-0.4 mmol/kg wet wt.) and K concentration unchanged (122.7+/-2.7 vs. 121.6+/-2.5 mmol/kg wet wt.) in PCT cells in NHE3-/- compared with NHE3+/+ mice. These findings suggest that the elimination of apical NHE3 in PCT cells of NHE3-/- mice reduces apical Na entry and, due to lower cell Na concentrations, Na/K-ATPase activity. The observed changes in intracellular Na concentration did not affect the expression of Na/K-ATPase in the renal cortex of NHE3-/- mice. There were no significant changes of cell Na concentration and Rb uptake in distal convoluted tubule, connecting tubule, principal and intercalated cells.     

Changes in element composition of A6 cells following hypotonic stress

Cellular element concentrations and dry weight contents were determined in A6 epithelia using electron microprobe analysis. This was done to assess the quantitative contributions of Na, K and Cl to the regulatory volume decrease (RVD) and isovolumetric regulation (IVR) after decreasing the basolateral osmolality from 260 to 140 mosmol/kg in a stepwise or gradual way. Two minutes after inducing acute hypotonic stress the cells behaved almost like ideal osmometers, as indicated by a pronounced increase in cell height and decreases in the cellular dry weight and concentrations of all measured elements by about the same degree. Sixty minutes after inducing acute hypotonic stress the dry weight and concentrations of the impermeant elements P, Mg and Ca had returned approximately to control values, indicating normalized cell volume. Na, K and Cl concentrations, however, remained greatly reduced. The cellular amounts of Na, K and Cl diminished during RVD by approximately 31%, 24% and 46%, respectively. The dry weights and element concentrations measured 60 min after inducing acute hypotonic stress were similar to those obtained after a continuous reduction of basolateral osmolality. The cellular loss of Na and K following hypotonic stress exceeded that of Cl by about 40 mmol/kg wet wt., suggesting the exit of an other anion and/or the titration of fixed negative charges. The contribution of Na, K and Cl to total cellular osmolality increased from about 75% under control conditions to about 85% during RVD and IVR. Since only approximately 70% of the loss of cellular osmolytes necessary for the observed RVD and IVR is accounted for by the cellular exit of Na, K and Cl, other osmolytes, possibly amino acids, must leave the cells following hypotonic stress.     

Increase in plasma lactate at the menopause and its relation to the "anion gap"

The mean plasma anion gap (Na + K + Ca + Mg)--(Cl + HCO3(-) + HPO4(2-) + protein), was significantly higher in post-menopausal women compared with pre-menopausal women (8.04 mEq/l compared with 7.03 mEq/l). This change was due, in part, to an increase in the plasma lactate concentration and to smaller increases in citrate and pyruvate concentrations. There were also changes in bicarbonate and chloride concentrations which suggested an increase pH of approximately 0.02 U. Together, these changes accounted for 46% of the increase in the "anion gap", leaving 54% unexplained. It is suggested that the rise in plasma lactate concentration may be due to mild alkalosis and that this change may account for the rise in plasma urate concentration which also occurs at the menopause.     

Involvement of Na and Cl in ouabain-induced cell swelling in thick ascending limb of rat kidney

Changes in the volume of isolated segments of rat medullary thick ascending limb (MAL) were studied by a photographic technique, after tubule incubation in isotonic solutions in the absence or presence of ouabain and/or K. When segments were incubated at 30°C in NaCl solution, their volume increased by 75% after removal of external K, and by 170% after removal of external K plus addition of 1 mmol/l ouabain. At steady state, tubular volume was a function of the external K concentration. Resting volume was obtained with external K concentrations higher than 0.1 and 1.0 mmol/l in the absence and presence of ouabain respectively. When MAL samples were incubated in isotonic K-free Na₂SO₄ or K-free choline Cl solution, their volume per unit of length was similar to that determined in NaCl medium, but there was no swelling after the addition of ouabain. The ouabain-induced swelling was shown to depend on both the Na and Cl concentrations in the incubate (apparentK _m of 87 and 80 mmol/l for Na and Cl respectively). Swollen tubules recovered their resting volume when ouabain, Na or Cl was removed from the incubation medium. Recovery of resting volume was also observed after addition of K into the incubation medium. These observations indicate that rat MAL cell volume is the result of coupled passive net fluxes of Na and Cl, which depend on the respective electrochemical gradients for Na or Cl across the cell membranes and the Na-pump activity which continuously extrudes Na.     

Na transport compartment in rabbit urinary bladder

Electron microprobe analysis was used to determine cellular electrolyte concentrations in rabbit urinary bladder. Under control conditions the mean cellular electrolyte concentrations were for Na 11.6±2.0, for K 124.1±15.3, and for Cl 26.0±5.1 mmol/kg wet weight. The dry weight content was 19.0±2.0 g/100 g. Inhibition of the Na/K-pump with ouabain resulted in drastic changes of the cellular element concentrations. Similar changes also occurred when in addition to ouabain the apical side was kept Na-free. In all epithelial layers the Na and Cl concentrations increased by 90 and 30 mmol/kg wet weight, whereas the K concentration and the dry weight content decreased by 90 mmol/kg wet weight and 6 g/100 g wet weight, respectively. With Na-free choline-Ringer's solution on the basal side ouabain led to a decrease in the K concentration by about 60 mmol/kg wet weight while the Na and Cl concentrations remained unchanged. These data indicate that the basolateral membrane is permeable to Na, choline, Cl, and K. Nystatin produced drastic changes in the cellular electrolyte concentrations when Na- or Rb-sulfate Ringer's solutions were present on the apical side. With Na-sulfate Ringer's solution the Na concentration increased by about 25, the Cl concentration by 30 mmol/kg wet weight and the dry weight content decreased by 4.5 g/100 g, respectively. With Rb-Ringer's solution about 20 mmol/kg wet weight of the cellular K was exchanged against Rb. The concentration changes were identical in all epithelial layers supporting the idea that the rabbit urinary bladder represents a functional syncytium with regard to the transepithelial Na transport.     

The acidosis of cholera. Contributions of hyperproteinemia, lactic acidemia, and hyperphosphatemia to an increased serum anion gap

To study the metabolic acidosis that occurs during the diarrhea of cholera, we examined the serum anion gap in 21 patients with hypovolemic shock due to Vibrio cholerae infection. Measurements of serum electrolytes, as well as divalent cations and the anionic contributions of serum proteins, lactate, phosphate, and serum creatinine, were made at the time of admission, after rehydration, and during convalescence. At the time of admission, the mean serum concentration of sodium was 134.8 mmol (meq) per liter, that of chloride was 103.2 mmol per liter, and that of bicarbonate was 11.4 mmol per liter; the mean anion gap was 20.2 mmol per liter. The mean serum creatinine concentration was 2.48 mg per deciliter. The low serum bicarbonate level and the high serum anion gap were corrected by rehydration. The increased serum anion gap was caused by hyperproteinemia, lactic acidemia, and hyperphosphatemia, with anionic contributions to the rise in anion gap estimated as protein, 5.5 meq per liter; lactate, 2.5 meq per liter; and phosphate, 2.5 meq per liter. The hyperproteinemia was attributed to dehydration, the lactic acidemia to shock, and the hyperphosphatemia to acidosis and transient renal failure. The mean concentrations of serum calcium and magnesium were slightly elevated but did not affect the increased anion gap. These results indicate that severe cholera causes acidosis with relatively little change in serum chloride but an increased serum anion gap. The acidosis is more profound than would be expected on the basis of stool losses of bicarbonate, because of superimposed lactic acidemia and renal failure.     

Effect of amiloride on electrolyte concentrations and rubidium uptake in principal and mitochondria-rich cells of frog skin

The role of mitochondria-rich cells (MR cells) in transepithelial Na transport was investigated by determining electrolyte concentrations and Rb uptake in individual cells of frog skin epithelium using electron microprobe analysis. Measurements were performed under control conditions and after blocking the transepithelial Na transport with amiloride. Under control conditions, Na and Cl concentrations of MR cells scattered much more than those of principal cells and ranged from a few up to more than 30 mmol/kg wet weight. Rb uptake from the basal side into individual MR cells also showed a large variation and was, on the average, much less pronounced than into the principal cells. In principal cells, amiloride reduced the Na concentration and Rb accumulation. In contrast, no effect was observed upon electrolyte concentration and Rb uptake of MR cells. Rb uptake was correlated to the Na concentration of MR cells both under control conditions and after amiloride. It is concluded that, in contrast to the principal cells, MR cells are not involved in amiloride-sensitive transepithelial Na transport and that their Na/K-pump activity is very low.