the extrarenal response to acute acid-base disturb

THE EXTRARENAL RESPONSE TO ACUTE ACID-BASE DISTURB-ANCES OF RESPIRATORY ORIGIN 1

By GERHARD GIEBISCH, LAWRENCE BERGER,2 AND ROBERT F. PITTS wrrH THETECHNICAL ASSISTANCE OF MARY ELLEN PARKS AND MARTHA B. MAcLEOD

(From the Department of Physiology, Cornell University Medical College, New York, N. Y.)

(Submitted for publication August 25, 1954; accepted October 20, 1954)

The plasma electrolyte changes in acute re-spiratory acidosis and alkalosis cannot be ex-plained solely on the basis of renal compensatorymechanisms. In acute respiratory acidosis, renalconservation of base is accomplished by means ofincreased excretion of ammonia and titratable acid(1) as well as by enhanced renal reabsorption ofbicarbonate bound base (2, 3). However, underacute conditions, the degree of base saving ef-fected by these means cannot account for the in-crement of bicarbonate bound base observed.This initial increment of bicarbonate bound basein the extracellular fluid which these renal tubularmechanisms then maintain, must be supplied fromextrarenal sources. Similarly, extrarenal media-tion must pertain in acute respiratory alkalosis,since altered renal excretion of base cannot aloneaccount for the extracellular electrolyte changeswhich occur (4). Furthermore, renal mechanismscannot explain completely the changes in plasmaconcentration of chloride, phosphate, and organicacids observed in acute respiratory acid-basedisturbances.The nature of the extrarenal compensation for

acid-base imbalances has been studied by variousapproaches. In metabolic acidosis, direct tissuestudies reveal alteration of the content of tissuephosphates (5), of sodium and potassium of boneand soft tissues (5), and of carbon dioxide storesof bone and muscle (6). The observed changesare interpreted to be evidence of direct tissue com-pensation. In addition, the buffering of infusedacid or alkali cannot be accounted for by bloodbuffers alone (7-9), nor by the buffer capacity ofthe extracellular fluid (10). Further, altered or-ganic acid metabolism has been invoked as capable

1Aided by grants from the National Heart Instituteof the National Institutes of Health and the Life In-surance Medical Research Fund.2Fellow of the National Heart Institute. Present ad-

dress: Mt. Sinai Hospital, New York, New York.

of modifying significantly the response of the or-ganism to an alkali invasion (11 ).Fewer studies exist as to the nature of the tis-

sue response to an acid-base disturbance of respira-tory origin. In this regard three lines of evidencecan be cited. First, studies in respiratory acidosisindicate that of the total carbon dioxide gained, 80to 90 per cent is accounted for by extravascularsites, largely bone and muscle (12, 13); con-versely, a loss of comparable degree from tissuesoccurs in respiratory alkalosis. Second, directmuscle analyses indicate changes in cell base inrespiratory acid-base imbalance (14, 15), whichmay be taken to reflect tissue compensation. Fi-nally, that tissue electrolytes may be made avail-able for extracellular buffering, has been postu-lated. Thus, various investigations have revealedchanges in carbon dioxide capacity (16, 17) ofblood, and alterations in plasma concentration ofvarious electrolytes of such magnitude and direc-tion to be compatible with transfer of these con-stituents across an extracellular boundary (18,19).The present study is an attempt to delineate

more precisely and completely the nature and ex-tent of the tissue contribution to the extracellularcompartment in the compensation for an acuterespiratory acidosis or alkalosis.

Nephrectomized dogs were used to eliminateany factor of renal compensation. By the meas-urement of extracellular fluid volume and ofplasma and red blood cell electrolyte concentra-tion, an estimate could be obtained of transfer ofions into or out of the readily available extracel-lular fluid volume.

Tissue contribution to compensation in the ex-tracellular fluid for respiratory acidosis or alka-losis was found to be mediated mainly by threemeans: Transfer of chloride across the erythro-cyte membrane; shifts of base across an extra-cellular boundary other than the red blood cell

231

GERHARD GIEBISCH, LAWRENCE BERGER, AND ROBERT F. PITTS

membrane; and significant alterations in organicacid content of the extracellular fluid.

EXPERIMENTAL PROCEDURE

A total of 29 experiments was performed on 24 maledogs, ranging in weight from 14.6 to 35.9 Kg. Anes-thesia was induced and maintained by sodium pentobar-bital, given intravenously. Bilateral nephrectomy wasperformed by flank approaches. Blood was obtainedfrom a needle indwelling in a femoral artery. A poly-ethylene catheter was inserted into the femoral vein,and used for administration of the various materials in-fused. An endotracheal airway with inflatable rubbercuff was introduced.Following these procedures, appropriate amounts of

sucrose, radiosulfate, and/or radiochloride (Cl") wereinfused in a manner previously reported from this lab-oratory (20). The total time for infusion includingwashout with 50 to 100 ml. of 3 per cent glucose in wa-ter never exceeded 15 minutes. In a total of three ex-periments the sucrose blank of plasma was followed overseveral hours of respiratory acidosis or alkalosis, andincrease in blank with time was found to be comparablewith that reported by Swan, Madisso, and Pitts (20).Appropriate blank correction was applied.In some experiments radiosodium (Na") was in-

fused. In such cases this material was given intrave-nously, 12 to 18 hours prior to the experiment to assureadequate equilibration. The dose used was usually 50 ;c,equivalent to about 8 X 100 cpm. Sufficient carrier wasadded to make a final concentration of 0.107 M NaCl.Correction was applied for radiosodium lost into theurine prior to nephrectomy.An equilibration time of two and one-half hours from

the midpoint of infusion was used for sucrose, radiosulfate,and for radiochloride. In 16 experiments, sucrose andradiosulfate were used simultaneously to estimate readilyavailable extracellular fluid volume.

Subsequent to equilibration time, blood was collectedfrom the indwelling arterial needle at hourly intervalsfor two to three hours. The amounts drawn each timevaried between 25 and 40 ml.

In acidosis experiments, following the control periodsthe dog breathed gas mixtures, usually containing 20per cent CO, and 80 per cent 0° for two to six hours.In a few experiments the gas mixture contained 12 percent CO, and 88 per cent 02. The gas was administeredby attaching a Douglas bag containing the mixture toa non-rebreathing Digby-Leigh valve which was con-nected to the endotracheal tube.

In alkalosis experiments, hyperventilation was main-tained for two to four hours by means of a Palmer-typerespiration pump attached to the endotracheal tube. Inthese experiments room air was used. In a few studiesthe initially induced period of acidosis or alkalosis wasfollowed by another set of control periods, during whichthe dog was allowed to breath room air spontaneously;these then were succeeded by two further periods during

which the condition opposite to that of the initial ex-perimental periods was induced: hyperventilation afterinitial CO, breathing or CO, breathing after hyperventila-tion.

ANALYTICAL METHODS

Plasma was analyzed for Na, K, Cl, CO., and P04 bymethods described previously (21). Values for pH weredetermined on samples of whole blood in the mannerdescribed by these authors. Lactate of plasma was esti-mated by the method of Barker and Summerson (22).Sucrose, radiosulfate, and Cl" of plasma were determinedby methods described in a previous report from thislaboratory (20). The gamma-emission of Na" ofplasma was measured in a lead-shielded scintillationcounter, containing a Thallium activated sodium iodidecrystal, and a steel filter for elimination of weak beta-emission. Determinations were performed on a 2 ml.wet sample in metal planchettes. A suitable Nae stand-ard in saline (0.107 M) was used. Comparison withstandards in plasma revealed no significant difference.Adequate sample and background counts were performedto assure a consistency of counting to within ±2 percent. By the analytical. methods used, complete separa-tion of Na" and Cl" could be achieved. No such com-plete separation could be accomplished in the case ofradiosulfate and Na", since the precipitates of radio-sulfate gave excessively high counts, due to contamina-tion with Na". Therefore, radiosulfate was not used inthe few experiments in which Na" was infused. Plasmavolume was estimated by the T-1824 dye-dilution tech-nique (23). A measure of total proteins of plasma wasobtained by the copper sulfate method of Van Slyke andhis associates (24). Hematocrit was measured in Win-trobe tubes, spun at 4,000 RPM in a centrifuge of 17 inchdiameter for 30 minutes. Whole blood analyses for Naand K were performed using an internal standard flamephotometer. Whole blood CO, content was determinedaccording to the method of Van Slyke and Neill (25).Whole blood chlorides were determined on a Van Slyke-Hawkins protein-free filtrate (26), an aliquot of whichwas analyzed by the method of Van Slyke and Hiller(27).

CALCULATIONS

Symbols and formulas used are given in detail in theAppendix. Total amounts of ions in the readily avail-able extracellular fluid (ECF) were calculated fromdata of plasma concentration, plasma volume, and radio-sulfate space (VS"O,), with appropriate factors appliedfor Gibbs-Donnan distribution and water content ofplasma. Total amounts of ions in the total red bloodcell mass were calculated from data of plasma concen-tration, whole blood concentrations, plasma volume, andhematocrit. The increments or decrements of total ex-tracellular or red cell ions were calculated in each ex-periment by averaging the total of each ion species incontrol periods and in periods of respiratory acidosis or

232

ION SHIFTS IN ACUTE RESPIRATORY ACID-BASE IMBALANCES

alkalosis. Increments are recorded as + AmM, decre-ments as -AmM. In experiments in which both aci-dosis and alkalosis were induced in the same animal, eachpair of periods (control, acidosis, or alkalosis), was com-pared to the immediately preceding pair.

RESULTS

Readily available ECF in respiratory acidosis andalkalosis in nephrectomized dogs

Figure 1 shows the plasma disappearance curvesof sucrose and radiosulfate of several representa-tive experiments. Similar curves were obtainedin all animals. It should be noted that the plotis a semi-logarithmic one. The vertical line indi-cates the time at which acidosis or alkalosis wasinduced.

It is apparent that in all cases a straight linecould be fitted through all points, since the logar-ithm of plasma concentration decreases linearlywith time.8 This linearity is compatible with con-

8 In the nephrectomized animal the slopes of the curvesof disappearance of radiosulfate and sucrose from plasmaare dependent on extrarenal removal of these substancesfrom the extracellular fluid. This extrarenal loss, suchas slow metabolic breakdown, secretion into the gastro-intestinal tract, etc., prevents these disappearance curvesfrom reaching a plateau. Recent experiments by Mulrow,Oestreich, and Swan (28) show that the slopes of disap-pearance from plasma of radiosulfate and sucrose remain

SUCROSEmg.%

in plosmo

S3504counts /mirtper cc. plosmo

-4 -2 0 +2 +4 +6

TIME IN HOURS(ZERO TIME TAKEN AT START OF ACIDOSIS OR ALKALOSIS)

FIG. 1. DISAPPEARANCE OF RADIOSULFATE AND SUQOSE FROM PLASMAIN NEPHRRECTOMIZED DoGs, SUBJECTD To RESPIATORY Acmosis ORALxALOSIs

233

stant clearance from unchanging volume of distri-bution (29). The conclusion, therefore, seemswarranted that neither the sucrose space (VS)nor radiosulfate space (VS8504) changed afterinduction of respiratory acidosis or alkalosis. In16 experiments the volumes of distribution of su-crose and radiosulfate were measured simultane-ously. The average ratio VS/VS8504 was foundto be 0.90. This value is in good agreement withthe value (0.91) recently given by Swan, Ma-disso, and Pitts (20). On the basis of the find-ings of the same authors, the radiosulfate spacewas selected as a measure of extracellular fluid.In 8 experiments where the radiosulfate space wasnot measured, its equivalent was obtained by mul-tiplying the sucrose space by 1/0.90. This pro-cedure appears permissible, since this ratio hasbeen shown to remain unchanged in respiratoryacidosis or alkalosis. From the data presentedthe conclusion is drawn that extracellular fluidvolume did not change in respiratory acidosis oralkalosis.

unchanged in the nephrectomized animal for as long as30 hours. The fact that no plateau is reached and thatno "flattening out" occurs, strongly indicates that de-crease in plasma concentration of these substances is notindicative of progressive increase in extracellular fluidvolume but of constant extrarenal removal of these sub-stances from an unchanging volume of distribution.

150

I~~~~~IA100I-14A80 - 2 Alk

I0 t Cl - b9AA

600 I

50 A

l1400-

1000. 1 2 Alk

800.:=a A

600-r% I 0 AC


TABLE I

Experiments ilustrating the effect of acute respiratory acidosis and alkalosis on distribution of dectrolytes

Quantity in readily available Quantity in total redConc. in plasma water extraceilular space blood cel volume

Elapsed Art. Plasmatime pH pCO Vs*o4 volume Na K Cl HCOs Na K Cl HCOs Na K Ci HCOa

mix. mm. Hg mt. H,O mM/L. mM mm150 7.30 46.5 4,610 753 155 3.2 108 23.4 682 14 517 113 83 5 38 9210 7.30 43.2 4,610 753 153 3.8 107 21.2 676 17 512 107 80 5 38 8270 7.29 43.2 4,610 753 150 4.0 107 20.7 668 18 516 100 79 5 37 7

275 20% COr-80% 02

330 6.84 173 4,610 678 158 4.3 108 30.6 701 19 517 147 91 7 50 15390 6.86 179 4,610 678 159 7.6 105 32.7 701 33 498 156 103 8 56 19450 6.89 173 4,610 678 161 8.0 103 33.4 713 35 492 159 100 8 SS 19510 6.81 199 4,610 655 162 7.8 106 32.5 717 34 502 15S 96 8 54 18570 6.84 176 4,610 655 163 6.9 104 31.0 723 30 497 148 89 6 51 17630 6.82 183 4,610 655 167 5.7 105 30.4 739 25 500 145 94 7 52 15

Dog 10 Ac--20.5 Kg. AmMols. +41 +13 -14 +45 +15 +2 +15 +9

150 7.39 43.3 5,270 948 162 3.8 114 26.6 820 19 617 146 125 8 86 16210 7.35 46.4 5,270 948 159 3.9 113 26.3 803 20 619 144 128 8 81 16270 7.40 39.9 5,270 948 161 4.0 112 26.3 814 20 613 141 121 7 76 15

275 Hyperventilation

330 7.74 6.6 5,270 854 159 3.3 113 8.9 800 17 619 49 116 8 74 7390 7.75 6.6 5,270 854 156 3.3 117 8.6 787 17 644 47 100 8 61 3450 7.73 6.6 5,270 854 159 2.8 120 8.1 803 14 659 44 94 8 57 3

Dog 2 Alk-23.6 Kg. AmMols. -16 -4 +25 -97 -22 0 -17 -12

Changes in electrolyte distribution in respiratoryacidosis and alkalosis

In Table I are presented data on electrolytechanges in the readily available extracellular fluidobtained in two typical experiments. Experiment10 Ac is one of 18 experiments in which respira-tory acidosis was induced. It is apparent thatthere was a marked drop in arterial pH and an

elevation of pCO2 to a level compatible with in-spiration of a 20 per cent CO2 mixture at atmos-pheric pressure. VS3504 remained unchanged, as

described above. Plasma volume was estimatedonce at the midpoint of each group of three pe-

riods. The value obtained was used in the cal-culations for the preceding and succeeding hourlyperiod. A decrease in plasma volume was usuallyobserved, possibly related to the repeated with-drawals of blood for analyses and to water trans-fer into red cells. Plasma electrolyte concentra-tions showed a progressive rise of sodium andpotassium, a slight fall of chloride, and a signifi-cant increase of bicarbonate. The next four col-umns show total electrolytes in the extracellular

fluid, and in the lowermost row are presented theincrements and decrements of these ions in theECF. It is evident that there was a transfer ofsodium and potassium into the ECF, a significantincrement of bicarbQnate, and a movement ofchloride out of the readily available extracellularfluid volume. The last four columns illustratesimilar data of total electrolytes and net transfersfor total red cell mass. Of special interest is thefinding that the chloride increment is of the sameorder of magnitude as the simultaneous chloridedecrement in the ECF.Experiment 2 Alk shows similar data in a

representative alkalosis study. The pH and pCO2changes here are typical of those in severe respira-tory alkalosis. Again, VS5504 remained un-changed. Plasma concentration data show changesopposite to those in respiratory acidosis; the bal-ance of total ions in the ECF demonstrates amovement of sodium and potassium out of theECF, a marked decrease in bicarbonate, and asignificant increment of extracellular chloride.In this case, red cell data again reveal a chloride

234


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TABLE III

Net transfers of ions in acute respiratory acidosis

VsOU4 V.,o,. Balance in readily available extraceilular space-mMExperiment Weight

no. Kilo. ml. HgO Na+ K+ C1- HCOs- POo Lact.

1 Ac 25.0 4,680* 4,220 + 8 + 2 -25 +342 Ac 14.9 3,150* 2,840 +22 + 5 -10 +253 Ac 17.0 4,025* 3,625 +22 + 1 0 +324 Ac 17.2 3,805* 3,425 +32 + 4 -10 +245 Ac 19.5 3,645 3,640 +16 +10 - 2 +306 Ac 22.0 4,025 3,345 +15 + 5 0 +367 Ac 19.9 3,855 3,455 +22 +10 -16 +428 Ac 21.1 4,415 3,805 +47 + 7 - 9 +668 A 17.0 2,780* 2,505 +27 + 5 - 8t +259 Ac 23.5 3,255 3,340 +20 + S + St +1310 Ac 20.5 4,610 +41 +13 -14t +4511 Ac 28.1 5,370 4,700 +53 + 7 - 8t +5512 Ac 19.6 4,305 4,320 +24 +15 + 8t +3913 Ac 25.4 5,670 5,440 +29 +26 -19t +439 Alk-Ac 35.9 6,545 6,210 +40 + 9 - 9 +72 +13 -9

11 Ac-Alk 23.6 5,040 +1S +13 -22 +38 + 5 -113 Alk-Ac 14.6 3,625 - + 9 + 2 -14t +29 + 6 +214 Alk-Ac 21.0 3,670* 3,300 +24 + 9 -lot +36 +15 -2

* S'O4 space estimated from sucrose space.t Red blood cell data obtained.

change of comparable magnitude but opposite interposed. The data show a marked rise of lac-direction to that in the ECF. tate associated with a slight fall of phosphate in

It is of importance that only about half of the respiratory alkalosis, and a significant increase indecrement in extracellular bicarbonate can be ac- phosphate with concomitant fall in lactate in pe-counted for by the observed concomitant changes riods of respiratory acidosis. These data reducein sodium, potassium, and chloride. A similar but the anion deficits formerly observed. Further-smaller discrepancy was evident in respiratory more, the total amounts of ions transferred intoacidosis. This discrepancy was considered too or out of the readily available extracellular fluidlarge to be explained, by alterations in known ca- are of comparable magnitude to those observedtions; therefore, the anions phosphate and lactate in separate experiments of acidosis or alkalosis.were studied in subsequent experiments. The net transfers of ions are reversible and re-The experiments listed in Table II illustrate two establishment of control conditions occurs to a

additional significant features. In these experi- reasonable extent after the pCO2 has been re-ments both alkalosis and acidosis were induced in stored to normal. This therefore illustrates thethe same animal, with appropriate control periods ready mobility of a fraction of body electrolytes in

TABLE IV

Net transfers of ions in acute respiratory alkalosis

vEiW4Veau Balance in readily available extracellular apace-mMExperiment weight --

no. Kilo. ml. H,0 Na+ KS ci- HCOJ- PO4 Lact.

1 Alk 22.3 4,040 3,555 -15 - 4 +17t - 632 Alk 23.6 5,270 4,390 -16 - 4 +25t - 973 Alk 20.9 4,755 4,150 -19 - 2 +12t - 875 Alk 24.1 6,400 S,965 -22 - 5 +20 -1106 Alk 22.5 4,575 3,940 -11 - 4 +13t - 517 Alk 19.9 4,470 3,695 -16 - 2 - St - 959 Alk-Ac 35.9 6,545 6,210 -15 - 2 +65 - 94 - 4 +35

11 Ac-Alk 23.6 5,040 - - 3 -22 +43 - 79 -11 +3212 Alk 16.4 2,685* 2,415 - 7 + 9 + 9t - 60 + 3 +2713 Alk-Ac 14.6 3,625 - -16 + 1 +19t - 58 - 6 +1514 Alk-Ac 21.0 3,670* 3,300 -14 - 2 +lot - 44 - 5 +21

* S04 space estimated from sucrose space.t Red blood cell data obtained.

236

RESPIRATORY ACID-BASE IMBALANCES

*10'

.6

ANom/L '

REDILYAVAILABLE

LC.F

*4.

O0

-2.

-4.

0 30 60 20 o50 o80 210

FIG. 2. TRANsFm OF SODIUM PER LITER OF READILYAVAILABLE EXTRACELLULAR FLUID, AS A FuNCTION OF

ARTERiAL pCOsEach point represents a separate experiment. The val-

ues at zero on the ordinate scale represent control periods.

contributing to buffering within the extracellularfluid.Experiment 14 Alk-Ac further demonstrates a

similar lability of red cell electrolytes. Again, the

.6-

+4.

AK

mlU/LREADILY

AVAILABLEE.C.F

+ 2

0-

- 2

- 4

extracellular chloride changes are of similar mag-nitude but opposite direction to those in the redcells.

In Tables III and IV are presented summariesof electrolyte transfers to or from the readilyavailable extracellular fluid in all experimentsperformed. Shown are the results of 18 obser-vations in respiratory acidosis and 11 observationsin respiratory alkalosis. The consistency of theabove described changes is evident. Variationsin the absolute amounts of ions transferred in in-dividual experiments are largely related to differ-ences in the size of the extracellular fluid volumesand to differences in severity of the acidosis or al-kalosis, i.e., the extent of alteration of arterialPCO2 (tide infra).

In a total of 8 acidosis experiments and 8 alka-losis experiments, red cell data were obtained.In the majority of observations the ACI of totalred cell mass was of similar magnitude, but op-posite sign to that of the ECF.'

4However, it should be pointed out that in vivo stud-ies of transfers of ions across the red cell membrane havecertain limitations. The possible sources of errors are:1) Changes in total body hematocrit may not be closelyreflected by the observed peripheral hematocrit (30);2) errors derived from estimating red cell concentra-

0 30 60 so 120 150 180 210

PCO2

FIG. 3. TRANSFER OF POTASSIUM PER LITER OF READILY AvAILABLE EXTRA-CELLuLAR FLUID, AS A FUNCTION OF ARTERIAL pCO2

Each point represents a separate experiment The values at zero on theordinate scale represent control periods.

* -

0

0~~~~~~~~~~

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I'0 0~~~~

0_

0

0 00

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237ION SHIFWTS IN ACUTE


In Figure 2 the ANa per liter extracellularfluid is plotted as a function of arterial pCO2.Each point represents a separate experiment. Thepoints massed at zero on the ordinate scale repre-sent pCO2 values of control periods. It is evidentthat there is a direct and fairly linear relationshipbetween the amounts of sodium transferred intoor out of one liter of extracellular fluid, and devia-tions of pCO2 from control values.A relationship similar in direction but smaller

in magnitude is presented for AK per liter extra-cellular fluid in Figure 3. Here again increasingamounts of base are transferred into the ECFwith increasing arterial pCO2.

Figure 4 depicts the interrelationship betweenACl per liter ECF and arterial pCO2. In thiscase the ACl per liter ECF is inversely related todeviations of pCO2 from control values, increas-ingly more chloride disappearing from the extra-cellular fluid as the pCO2 is raised.

tion of ions from whole blood, plasma, and hematocritdeterminations may result in apparent transfers; 3) newcells which may be released into the circulation may nothave the same average composition as those already inthe blood stream (31).

*6G

AclmMI/L * 4

READILYAVAILABLE

ECF. .

- 2

-4-

0 30 60 90 120

PCO2

150 ISO 210

FIG. 4. TRANSER OF CHLORIDE PER LITER OF READILYAvmLELz EXTRACELLULAR FLUID, AS A FUNCTION OF

ARTERAL pCO,Each point represents a separate experiment The

values at zero on the ordinate scale represent controlperiods.

.20<'0 CHANGE IN PLASMA J1Ns10-(91- HCOs]S CHANGE IN PLASMA [(PQ,+.L.et.].16

millimols .8 )per liter of

plasmo P

.4.Q

IO N I C S A*12~~~~~Po

FIG. 5. VARIAnONS INi ANION DEFICIT, AS A FUNCTIONOF ARTERIAL pCO,

The points at zero on the ordinate scale represent con-trol periods. The anion deficit (Na + K) - (Cl +HCO,), and the sum of plasma phosphate and lactate ofcontrol periods are arbitrarily taken as zero. Each pointrepresents one experiment. The two curves are drawnfree-hand.

Figure 5 illustrates the manner in which phos-phate and lactate contribute to the diminutionof the anion deficit previously discussed. Thisdeficit, expressed as the function [ (Na + K) -(Cl + HCO)] of plasma, is found to increaseboth in acidosis and alkalosis, more so in the latter.In the experiments performed, the sum of plasmaphosphate and lactate ($[PO + lactate] ) wasfound to rise with deviations from control pCO2.The graph depicts the relationship between theincrease of [PO + lactate] of plasma above con-trol values and the increase of anion deficit. Itshould be noted that in respiratory acidosis thephosphate ion accounts for the greater part of thisdeficit, and in respiratory alkalosis the lactate ionis predominant. The degree to which phosphateand lactate do not completely account for the aniondeficit indicates that other anions are involved.

In an attempt to elucidate further the mecha-nism of the observed ion shifts, experiments wereperformed in which exchangeable pools of sodiumand chloride were determined. In some experi-ments the volume of distribution of radiochloride(VClM) was estimated. Table V illustrates ob-

* .

0~ ~ ~ ~ ~ ~

*8~~~~~~~0

238


TABLE V

Experiments illustrating the effect of acute respiratory acidosis or alkalosis on the exchangeable pool of sodium andchloride, and the volumes of distribution of radiochloride

Elapsed Exchangeable Na+ Exchangeable C1- VcI#timemix. mM mM/Kg. mM mM/Kg. ml. H2O % Body wt.

Experiment no. 8 A Control

150 684 40.4 508 30.3 4,170 24.7210 713 42.2 500 29.6 4,100 24.3

20% C0X-80% 02

270 684 40.1 498 29.5 4,180 24.7330 692 40.8 522 30.9 4,380 25.9

Experiment no. 14 Alk-Ac Control

150 994 47.3 586 27.9 5,090 24.2210 1,002 47.8 603 28.7 5,170 24.6

Hyperventilation

270 997 47.4 603 28.7 5,075 24.2330 969 46.1 606 28.9 5,155 25.5

servations in typical experiments. Table VIshows the deviations from control values in allacidosis and alkalosis experiments. The smalland inconsistent changes observed are not re-garded as significant.

DISCUSSION

Qualitatively, the observations presented aboveon ion shifts between extracellular and cellular

TABLE VI

Summary of deviation from control values of exchangeablesodium, exchangeabk chloride, and chloridem space

Average % deviation from control

Exchange- Exchange-Experiment able able

no. Na Cl VcIS

Respiratory acidosis

1 Ac +2.6 -2.0 +1.72 Ac +3.1 +2.6 +5.03 Ac +2.3 +0.5 +0.94 Ac +1.7 +4.214 Alk-Ac -2.5 +5.6 +7.38 A . -1.9 +0.7 +3.3

Respiratory alkalosis

12 Alk 0.0 +1.7 -1.514 Alk-Ac -1.9 +1.8 +2.0

or supportive structures in respiratory acidosisand alkalosis are independent of the nature of thesubstance employed in measuring extracellularfluid volume. Quantitatively, the magnitude ofthe shifts observed are of course dependent on thevolume measured and thus on the nature of thesubstance employed. We have chosen the volumeof distribution of radiosulfate as a measure ofreadily available extracellular fluid on the evidenceof Swan, Madisso, and Pitts (20). We definereadily available extracellular fluid as plasma andthat fraction of the interstitial fluid with which itis in ready diffusion equilibrium.

Following nephrectomy, neither the measuredvolume of extracellular fluid (20), nor its elec-trolyte content, changes significantly over severalhours (32). As shown above, the volume ofdistribution of radiosulfate remained unchangedin consequence of the induction of either severerespiratory acidosis or alkalosis. That extracel-lular fluid volume remained unchanged is furthersupported by the observation that the volumes ofdistribution of sucrose and radiochloride likewiseremained unaltered. Possible errors in estimatingextracellular fluid electrolyte content includechanges of Gibbs-Donnan distribution factor withchanges in pH, and changes in the readily avail-

239


able extracellular fluid volume by water transfers(33, 34) not detected by the methods used. Inour experiments, the calculated transfer of waterinto red cells in respiratory acidosis, based on fiveobservations, reveals a shift of the magnitude ofabout 2.0 per cent of the total ECF, a value wellwithin the limits of error of estimating the volumeof distribution of radiosulfate. In three alkalosisexperiments the water shift out of red cells wassimilarly only 1.5 per cent of the measured ex-tracellular fluid volume. These changes are be-lieved to be too small to affect the conclusionsdrawn.The data presented indicate that significant

redistribution of electrolytes occurs in respiratoryacidosis and alkalosis in the absence of renal com-pensatory mechanisms. In acute respiratory aci-dosis, the decrease of fixed acid and the increase ofbase in the extracellular fluid permit the expan-sion of buffer anions to a degree which diminishesconsiderably the severity of the developing acido-sis. Similarly, in acute respiratory alkalosis ofthe severity induced in these experiments, com-pensatory reduction of buffer anions in the extra-cellular fluid occurred, thereby preventing the de-velopment of a lethal alkalosis.5To depict the participation of these mechanisms

in the changes of buffer content observed, Figures6 and 7 are presented. These graphs are basedon observations limited to those experiments inwhich all the respective ions have been determined.Since a fair degree of variation occurs, they indi-cate general trends of responses to acute respira-tory acidosis and alkalosis. In Figure 6 the totalincrement of buffer anions of the extracellular

5 In the case of respiratory acidosis, induced by breath-ing a 20 per cent CO, mixture, the H,CO concentrationof plasma would rise theoretically to about 5 mM per L.If [BHCO,] remained unchanged, then the normal ra-tio [BHCOsJ/[H,CO] of 20: 1 would change to 4:1,resulting in a pH of 6.70. In most of our experiments,pH ranged about 6.88, indicating an alteration of this ra-tio to 6: 1. Thus extrarenal compensation effected an in-crease in [BHCO,] of approximately 10 mM per L. ofplasma. A similar analysis of the situation in acuterespiratory alkalosis of the degree achieved in our ex-periments, where [H.CO] falls to approximately 0.2mM per L., reveals that were no compensatory displace-ment of [BHCO,] to occur, a pH of 8.1 would result.That the pH rises only to approximately 7.7 indicatesthat extrarenal compensation has permitted a fall of[BHCO,] of about 12 mM per L. plasma.

RESPIRATORY ACIDOSIS

TOTAL INCREASEIN BASE BOUND

BY BUFFER[14% HP04186% HCOjJ

UNACCOUNTED

No* TRANSFERRED INTOREADILY AVAILABLE E.GF.

K* TRANSFERRED INTOREADILY AVAILABLE E.CF.

CHLORIDE TRANSFERREDINTO RED CELLS

LACTATE DECREASEBASE FREED FROMPLASMA PROTEIN

FIG. 6. THE MODE OF ExTRACELLULAR BUFFENG IN

AcuTE RESPIATORY AcmOsisData from four experiments are averaged (9 Alk-Ac,

11 Ac-Alk, 13 Alk-Ac, 14 Alk-Ac). Gas mixtures usedwere in all. experiments 20 per cent CO2 to 80 per cent 02.In Figures 6 and 7 HPO,- was calculated using the Hen-derson-Hasselbalch equation assuming a pK' for phos-phate of 6.8.

fluid during acute respiratory acidosis is repre-sented by the total height of the column. Thelargest fraction of this increment in buffer anionsis due to the increase of bicarbonate and only toa slight extent to the increment in basic phosphate(HPO4=). The contributions of the various ionspecies to the total increase are expressed as per-centages.Only a small portion of the total increase is

mediated by a decrease in base binding of plasmaproteins (35) as consequence of the pH fall (5per cent) and by decrease of the fixed acid anionlactate (6 per cent). As can be seen, the majorportion of buffer anion increase is made possibleby fixed acid chloride leaving the extracellularfluid (29 per cent) and base being transferredinto it. The total cation increment is made upof sodium (37 per cent) and potassium (14 percent). The fraction unaccounted for (9 per cent)probably represents changes in undetermined con-stituents, such as organic acids, calcium, andmagnesium.

Figure 7 is a similar representation of changesobserved in acute respiratory alkalosis. In thisinstance the total height of the column indicatesthe degree of buffer anion decrement in the ex-tracellular fluid. Again, only a very small part is

240


RESPIRATORY ALKALOSIS

UNACCOUNTED

No* TRANSFERRED OUT OFREADILY AVAILABLE E.CF.K' TRANSFERRED OUT OFREADILY AVAILABLE E.C.F.

BASER d e s CHLORIDE TRANSFERREDBY SUFFER

lo% HNP041L90%HCO3

LACTATE INCREASE

BASE BOUND BYI PLASMA PROTEIN

FIG. 7. THE MODE OF EXTRACELLULAR BUFFERING IN

AcuTE RESPiRATORY ALALOSIsData from five experiments are averaged (9 Alk-Ac,

ilAc-Alk, 12 Alk, 13 Alk-Ac, 14 Alk-Ac). The pCO2in these experiments uniformly fell to levels of 6 to 8mm. Hg.

due to altered base binding of plasma proteinates(1 per cent). However, the increase in lactatemarkedly contributes to the displacement of bufferanion (35 per cent). Further displacement ofbuffer anion is effected by transfer of chloride intothe extracellular fluid (37 per cent) and disap-pearance of sodium (16 per cent) and potassium(4 per cent) from it. The remaining undeter-mined 7 per cent may include changes in variousother anions or cations, such as keto-acids andserum calcium (36).

In the following an attempt is made to analyzein somewhat more detail the pertinent changes infixed acid and base which occur in the nephrec-tomized animal during respiratory acid-base dis-turbances.

Changes in blood lactate levels have been ob-served repeatedly in alkalosis of respiratory andmetabolic origin (11, 37, 38). So far, the preciseetiology of these alterations is not known, butseveral factors may be involved in its origin.Peters and Van Slyke (38) have suggested thatin an alkaline medium, hemoglobin may deliveroxygen to the tissues less efficiently because of theshift to the left of its oxygen dissociation curve

(39), thus favoring anaerobic glycolysis. Simi-larly, circulatory stasis, related to lowering ofblood pressure (36) and peripheral vasoconstric-tion (40), both of which are known to occur in

respiratory alkalosis, may lead to lack of availableoxygen.A somewhat different view is presented by

Katzman, Villee, and Beecher (41) . In titrostudies of tissue slices in an adequately oxy-genated environment indicate that with bicarbo-nate concentration of the system kept constant,lactate production varies inversely with pCO,.This may be interpreted to reflect a direct effectof carbon dioxide partial pressure on lactate me-tabolism. A further factor, suggested by severalauthors (42) has been increased epinephrine se-cretion. The markedly increased lactate levelsobserved in respiratory alkalosis are probably theresult of a combination of the above factors, allof which favor anaerobic glycolysis. Our ex-periments, in which both alkalosis and acidosiswere induced, indicate that these alterations inlactate metabolism are readily reversible.

Regarding the chloride changes observed, it hasbeen found in animals with intact kidneys thattotal plasma anion concentration (Cl + HCO8)is maintained in the presence of marked altera-tions of anion pattern (43). Thus, an inverserelationship between plasma chloride and bicarbo-nate has been observed in respiratory acid-basedisturbances (44). Our experiments show thatthis condition holds in the arenal animal as well.Therefore, these changes must be due to trans-fers of chloride and bicarbonate across an extra-cellular boundary. Our experimental results in-dicate that the chloride shift across the red cellmembrane, as classically described for whole bloodby various authors (45, 46), appears of sufficientmagnitude to account for all the chloride whichleaves the extracellular fluid in respiratory aci-dosis, or conversely, enters it in respiratory alka-losis. In this manner the significant buffer ca-pacity of the red cell, largely in the form of hemo-globin, is made available to the extracellular fluid.In some experiments, however, the chloride shiftto or from the extracellular fluid seemed largerthan could be accounted for by a red cell transferalone. The possibility remains, therefore, thatchloride shifts may occur across some other ex-tracellular boundary. Our data certainly indicatethat a significant fraction of exchangeable chlo-ride does exist outside of the readily availableextracellular space.

241


Alteration of extracellular base content was aregular finding in the studies reported. In re-spiratory acidosis a discharge of sodium and po-tassium into the readily available extracellularspace occurred consistently. These moieties pre-sumably were derived from cells or supportivestructures. Our data indicate that the red cellsare not responsible for the cation transfers ob-served. Conversely, extracellular cations musthave entered cells or/and supportive structures inrespiratory alkalosis. It seems likely that sodiumand potassium were exchanged mole for mole forhydrogen ions in this process (10). The transfersof sodium occurred without alteration in the sizeof the exchangeable sodium pool as measured byradiosodium. The store of exchangeable bonesodium is potentially large (47). Evidence indi-cates that this reserve of base may be called uponin the maintenance of extracellular ion composi-tion (48, 49) in acid-base disturbances. Underthe acute conditions of our experiments, exchangesapparently represent redistribution of sodiumwithout mobilization of previously non-exchange-able sodium. Balance studies conducted in humansubjects by Singer, Elkinton, Barker, and Clark(50) (based on the chloride space), have revealedshifts of cell base in acute respiratory acidosis andalkalosis comparable to those reported here.

Significant changes in plasma inorganic phos-phate levels were in accord with older observationsof Haldane, Wigglesworth, and Woodrow (51)who found a significant rise in respiratory acidosis,and a fall in alkalosis. Similarly, Fitz, Alsberg,and Henderson (52) and Goto (5) showed earlierthat the large intracellular stores of organic phos-phate may be drawn upon in furnishing extracel-lular buffer anion. On the other hand, an increasein intraerythrocytic organic acid soluble phos-phorus has been demonstrated in metabolic alka-losis (53). The etiology of these changes hasbeen studied by Mackler and Guest (54). Theseauthors observed that acidosis inhibits phos-phorylation of glucose, both in vitro and in vivo.In this connection, the older finding of Lawaczeck(55), which showed that an increase of hydrogenion concentration, induced by an increase in pCO2,accelerates hydrolysis of red cell organic phos-phates, may be pertinent.

Bicarbonate is the most important of the extra-cellular buffer anions; alterations of its content

mirror changes in the reserve of physiologicallyavailable buffer alkali in the body (38). All ourexperiments reveal no significant further altera-tion of extracellular buffer content (largely bi-carbonate) after the first hour. It therefore ap-pears that in acute respiratory acidosis and alka-losis of the nature induced in these experiments,the major portion of extracellular buffering, andconsequently the major portion of ion transfers,is achieved within this period of time.

SUMMARY AND CONCLUSIONS

1. In 29 experiments performed on nephrec-tomized dogs, acute respiratory acidosis and al-kalosis were induced.

2. Volumes of distribution of radiosulfate, ofsucrose, and of radiochloride did not change.From these findings, it is concluded that extra-cellular fluid volume remained unaltered.

3. Significant redistribution of electrolytesacross the boundary of the readily available ex-tracellular fluid volume was observed.

4. Tissue contribution to buffering within theextracellular fluid was found to be mediated bythe following mechanisms:

a) Transfer of chloride across the erythro-cyte membrane;

b) shift of sodium and potassium across an ex-tracellular boundary other than the red cellmembrane;

c) transfer of inorganic phosphate across anunknown extracellular boundary;

d) significant alterations in lactate metabolism.

ACKNOWLEDGMENTS

We would like to express our appreciation to Drs. H.D. Lauson and R. C. Swan for helpful advice.

APPENDIX

The following symbols and calculations were used toderive data on electrolyte content of extracellular fluid andred cells:1) Water correction, when used, was calculated as:

W = 1 - P.

whereW = plasma water correction factorP. = plasma proteins in grams per 100 ml. plasma

242


2) Cw cpw

Cw = concentration in plasma water (mM per liter)Cp = concentration in plasma (mM per liter)

3) CR CE (1 H) CpH

where

CR = concentration in red blood cells (mM per literof cells)

CB = concentration in whole blood (mM per literwhole blood)

H = Hematocrit, expressed as a decimal fraction.No correction was applied for trapped plasma

4) V8 = Is w

Vs = volume of distribution of sucrose (ml. H20)Is = amount of sucrose injected (mg.)Co = plasma concentration of sucrose at zero time

(mg. per ml.)Co was obtained by extrapolating to zero time a

straight line which could be fitted by eye to the valuesof the logarithm of successive plasma concentrationsplotted against time.

5) The volume of distribution of radiosulfate was esti-mated by a slightly modified formula, suggested byGamble and Robertson (56).

VSo4= W.PV + [!IWv ]

VsXo4 = volume of distribution of S3504 (ml. H20)PV = plasma volume (ml. plasma)D = Donnan factor for S"30,, taken as 1.1 (20)

IS*o4 = amount of 350Q injected (counts per min.)Co = concentration of S36O4 at zero time, in counts

per minute per ml. plasma. Co was obtainedin a manner similar to that described for Coof sucrose.

6) VCu=W.PV + W [ICI PV]

Volume of distribution of C1l was determined byFormula 5, save that D = 1.05, and Ct is taken as

the concentration of C186 in counts per min. per ml.plasma at the hourly intervals.

7) Plasma volume was determined once in control periodsand once every two to three hours thereafter.PVc = PV.WPVc = volume of distribution of T-1824 (taken as

estimate of plasma volume) in ml. H20.PV = plasma volume in ml. plasma

8) Total amounts of electrolytes in the readily availableextracellular fluid (ECF) were obtained by use of dataof plasma concentration, plasma volume, interstitialfluid volume, and appropriate Donnan and watercorrection factors. The following formula was used:

TIC +PVSno. -p3C-

TE = total mM in VS0o4D = Donnan factor, 0.95 for Na and K.

1.05 for Cl and HCOs.No Donnan factor was used for P04 and lactate.

9) Total amounts of electrolytes in the total red bloodcell volume were calculated by use of data on red bloodcell concentration, plasma volume, and hematocrit.No correction for excess plasma or excess red cellswas applied because of the findings of Reeve, Greger-sen, Allen, and Sear (30) that the ratio of total bodyhematocrit to peripheral hematocrit varied from 0.9to 1.1 in dogs under different experimental conditions.The following formula was used to calculate totalelectrolytes in red cell volume:

T = CR PV PV1000I1-H

Tc = total red cell electrolytes in mM.10) Base binding of plasma proteinate (BPs in mEq. per

L.) was estimated according to Singer and Hastings(35).

11) Exchangeable sodium and chloride were estimated inthe usual way (57).

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the extrarenal response to acute acid-base disturb

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