The basics of acid base disorders

[mattyb]

I know a lot of people around here have been having a tough time understanding acidity/alkalanity, and these terms get used a lot on this forum, so I figured I would make a basic primer on acid-base disorders. Keep in mind that this is a BASIC primer and reality is much more complicated. But knowing the basics is a really good start. I will be writing this in parts. What's below if Part 1.

Keep in mind that I used the word alkaline and basic interchangeably, since they mean the same thing.

Part 1 - The absolute basics

What is an acid, and what is base?
In medicine, acids and bases are defined with the Brownsted-Lowry criteria. This means that an acid is any molecule that can donate a proton (typically a positively charged hydrogen [H+]), and a base is anything that can accept a proton (typically a negatively charged hydroxide [OH-]). So an acidic solution has more free H+ ions, and a basic solution more free OH- ions. There are Lewis acids/bases as well, but those aren't relevant for this discussion, since acidity/alkalinity in medicine is not defined with Lewis criteria. Lewis acids/bases are still interesting and very biologically relevant though, so if you are interested read up!

How is acidity/alkalinity defined?
It's simple. 7 is a neutral pH in any general solution. In the human body, blood pH is generally regulated between 7.35-7.45. Anything below 7.35 is considered acidic (more H+, less OH-). Anything above 7.45 is considered basic (less H+, more OH-). Anything in between is neutral.

But it gets more complicated. Cells get more acidic the more interior you go. So the nucleus is more acidic than the cytosol. Then in the body different organs and tissues have different ideal pHs. The stomach is the most acidic organ in the body with an interior pH of about 1.5-2. The pancreas, liver, etc., have higher pHs around 7.5-8. Your muscle pH changes based on your activity level (gets more acidic when you exercise). This goes on and on.

But it's important to know that when we talk about acid-base disorders in medicine, they are defined by arterial, and sometimes venous, blood pH.

What makes things acidic or basic in the human body?
The primary regulator of acidity and alkalinity is carbon dioxide (CO2). CO2, with the aid of carbonic anhydrase and water, can convert to the acidic carbonic acid (H2CO3) and then the basic bicarbonate (HCO3-). So high CO2 typically means high acidity in the body, because it rapidly converts to carbonic acid, loses an H+, and becomes bicarb. The primary way the body balances this acid base balance is through respiration. The faster your body expels CO2 through breath, the less acidic you become. In this process, HCO3 loses CO2, leaving OH-, and the OH- combines with H+ to form water, which neutralizes acidity. Some excess H+ ions are filtered out of the body through urine as well, and in this process of losing hydrogen, bicarb is reformed, so you become even more basic.

Below are a list of acidifying or alkalizing agents. This is by no means comprehensive, this is just a basic primer after all.

Common physiological acidifying agents
Carbon dioxide
Hydrochloric acid
Lactate
Phosphoric acid
Ketones
Fatty acids

Common physiological alkalizing agents
Bicarbonate
Phosphate

Mixed buffers (they can act as either acids or bases)
Proteins - but more often they act as bases and are a major sink for excess H+ ions.

That's it for today! I'll start Part 2 when I have some more time. Part 2 will discuss common acid-base disorders like respiratory and metabolic acidosis/alkalosis.

 

[jaa]

Thanks for writing this matty! I look forward to the rest of the series.

I'm a bit confused about the CO2 being acidic part. If it ultimately ends up as bicarb, why doesn't it make us basic?

 

[JDD]

Cool, good idea for a topic. Someone posted one of these videos on another part of the forum, I found them to be very helpful. https://www.youtube.com/watch?v=lZOCmv3JK8w&list=PL2FGqyNNJYSxmoKj-N3RdsbRZArnWK0C2

 

[mattyb]

Thanks for writing this matty! I look forward to the rest of the series.

I'm a bit confused about the CO2 being acidic part. If it ultimately ends up as bicarb, why doesn't it make us basic?

So H2CO3 forms quickly from CO2, and then releases one H+ to form HCO3-. Acidity is defined as the concentration of H+ ions, so the conversion of H2CO3 -> HCO3- increases acidity because an extra H+ is added.

But the problem is bicarb doesn't absorb that extra H+ as easily as H2CO3 lets it's H+ go. So the rate of reaction is unequal, it will always favor excess H+ if left alone. Where it balances out is through respiration. At the lungs, with the help the enzyme carbonic anhydrase, the HCO3- is converted back to H2CO3 and then to H20 + CO2, and the CO2 is expelled and all we're left with is water.

So HCO3- can act as a sink for H+ but it doesn't work that well. Where it balances out acidity is that it can absorb a stray H+ at the lungs and that H+ is then integrated into water. This lowers the acidity of the system by removing excess H+. And in essence, we essentially do end up being a little more basic than we are acidic (our resting blood pH is slightly alkaline at 7.4). I hope that clears it up?

 

[Canari]

Thanks for the exciting story!

CO2, with the aid of carbonic anhydrase and water, can convert to the acidic carbonic acid (H2CO3) and then the basic bicarbonate (HCO3-). So high CO2 typically means high acidity in the body, because it rapidly converts to carbonic acid, loses an H+, and becomes bicarb.

The part I have a question about is WHY CO2 converts to carbonic acid? And are there differences between people about it?

 

[Aleksandr]

Nice post MattyB! Look forward to part 2.

 

[Aleksandr]

tzar 'vodka'(bolotov's balm)... gbold said that that balm corrects acid base imbalance. Have you read about it before? Is its action basically the same as taking HCL? It increases acidity temporarily, and then afterwards it makes you more alkaline?

(I.e. good for those who are naturally more towards the acidic side?)

https://acikgunluk.net/balzam-bolotova-primenenie-i-sostav/


https://www.youtube.com/watch?v=dUOWvo2rBP0

google translated:
THE RECIPE FOR PREPARATION OF BALOTOV'S BALSAM ("CARGO VODKA"):
Take 1 liter of water, it adds a half glass of grape vinegar.
Further, we pour into this jar 1 tablespoon (1-2 teaspoons) of sulfuric acid (96%),
then pour in 1-2 teaspoons of hydrochloric acid (38%),
and it is in this sequence -

first the heavy fraction is sulfuric acid,
then easy - hydrochloric.
And add 4 tablets of nitroglycerin.

BALSAM READY.
In a liter bottle, then, you can drop a pod of pepper, which is not only very useful, but gives us the bitterness we need.
In the presence of many diseases and to increase the effect in the balm add in the amount of 1-3 tablets (ampoules):
acetylsalicylic acid, succinic acid,
amino acids: methionine, methylalanine, tryptophan.
You can supplement balsam with adrenaline and heparin.
*************************************
BV Bolotov:
"This is not a cure, but the elimination of the reasons that we accumulate in ourselves with the loss of heat of the body, with the loss of salt lymph.
The main element of the gastrointestinal tract is the gastric juice. 99% of it is absorbed back into the blood. Gastric juice walks all over the body, splits damaged, dead cells. He can not dissolve only his own young cells (which is necessary for health).

 

[mattyb]

Thanks for the exciting story!

CO2, with the aid of carbonic anhydrase and water, can convert to the acidic carbonic acid (H2CO3) and then the basic bicarbonate (HCO3-). So high CO2 typically means high acidity in the body, because it rapidly converts to carbonic acid, loses an H+, and becomes bicarb.

The part I have a question about is WHY CO2 converts to carbonic acid? And are there differences between people about it?

Carbonic anhydrase converts CO2 to H2CO3 which then dissociates into HCO3- + H+. Carbonic anhydrase is bidirectional, facilitating both the formation of carbonic acid, and it's return to carbon dioxide and water.

So the formula is:
CO2 + H2O -> H2CO3 -> HCO3- + H+ and it can go both ways easily thanks to carbonic anhydrase.

 

[mattyb]

tzar 'vodka'(bolotov's balm)... gbold said that that balm corrects acid base imbalance. Have you read about it before? Is its action basically the same as taking HCL? It increases acidity temporarily, and then afterwards it makes you more alkaline?

(I.e. good for those who are naturally more towards the acidic side?)

https://acikgunluk.net/balzam-bolotova-primenenie-i-sostav/


https://www.youtube.com/watch?v=dUOWvo2rBP0

google translated:
THE RECIPE FOR PREPARATION OF BALOTOV'S BALSAM ("CARGO VODKA"):
Take 1 liter of water, it adds a half glass of grape vinegar.
Further, we pour into this jar 1 tablespoon (1-2 teaspoons) of sulfuric acid (96%),
then pour in 1-2 teaspoons of hydrochloric acid (38%),
and it is in this sequence -

first the heavy fraction is sulfuric acid,
then easy - hydrochloric.
And add 4 tablets of nitroglycerin.

BALSAM READY.
In a liter bottle, then, you can drop a pod of pepper, which is not only very useful, but gives us the bitterness we need.
In the presence of many diseases and to increase the effect in the balm add in the amount of 1-3 tablets (ampoules):
acetylsalicylic acid, succinic acid,
amino acids: methionine, methylalanine, tryptophan.
You can supplement balsam with adrenaline and heparin.
*************************************
BV Bolotov:
"This is not a cure, but the elimination of the reasons that we accumulate in ourselves with the loss of heat of the body, with the loss of salt lymph.
The main element of the gastrointestinal tract is the gastric juice. 99% of it is absorbed back into the blood. Gastric juice walks all over the body, splits damaged, dead cells. He can not dissolve only his own young cells (which is necessary for health).

No freakin clue about any of that, but it sounds crazy haha. Sounds super acidic.

Let's try to keep things on topic in this thread though.

 

[Aleksandr]

tzar 'vodka'(bolotov's balm)... gbold said that that balm corrects acid base imbalance. Have you read about it before? Is its action basically the same as taking HCL? It increases acidity temporarily, and then afterwards it makes you more alkaline?

(I.e. good for those who are naturally more towards the acidic side?)

https://acikgunluk.net/balzam-bolotova-primenenie-i-sostav/


https://www.youtube.com/watch?v=dUOWvo2rBP0

google translated:
THE RECIPE FOR PREPARATION OF BALOTOV'S BALSAM ("CARGO VODKA"):
Take 1 liter of water, it adds a half glass of grape vinegar.
Further, we pour into this jar 1 tablespoon (1-2 teaspoons) of sulfuric acid (96%),
then pour in 1-2 teaspoons of hydrochloric acid (38%),
and it is in this sequence -

first the heavy fraction is sulfuric acid,
then easy - hydrochloric.
And add 4 tablets of nitroglycerin.

BALSAM READY.
In a liter bottle, then, you can drop a pod of pepper, which is not only very useful, but gives us the bitterness we need.
In the presence of many diseases and to increase the effect in the balm add in the amount of 1-3 tablets (ampoules):
acetylsalicylic acid, succinic acid,
amino acids: methionine, methylalanine, tryptophan.
You can supplement balsam with adrenaline and heparin.
*************************************
BV Bolotov:
"This is not a cure, but the elimination of the reasons that we accumulate in ourselves with the loss of heat of the body, with the loss of salt lymph.
The main element of the gastrointestinal tract is the gastric juice. 99% of it is absorbed back into the blood. Gastric juice walks all over the body, splits damaged, dead cells. He can not dissolve only his own young cells (which is necessary for health).

No freakin clue about any of that, but it sounds crazy haha. Sounds super acidic.

Let's try to keep things on topic in this thread though.

Ah ok. I thought it might work similar to hydrochloric acid as in the 'acidifying agents' category

 

[jaa]

I hope that clears it up?

It does. Thanks!

 

[Canari]

Thanks for the exciting story!

CO2, with the aid of carbonic anhydrase and water, can convert to the acidic carbonic acid (H2CO3) and then the basic bicarbonate (HCO3-). So high CO2 typically means high acidity in the body, because it rapidly converts to carbonic acid, loses an H+, and becomes bicarb.

The part I have a question about is WHY CO2 converts to carbonic acid? And are there differences between people about it?

Carbonic anhydrase converts CO2 to H2CO3 which then dissociates into HCO3- + H+. Carbonic anhydrase is bidirectional, facilitating both the formation of carbonic acid, and it's return to carbon dioxide and water.

So the formula is:
CO2 + H2O -> H2CO3 -> HCO3- + H+ and it can go both ways easily thanks to carbonic anhydrase.

Sorry.... I meant something else when I asked WHY. As you said "CAN convert", does it mean it does not always do it? (or not that quick, or not that much...) Then why it does or does not convert, and according to what criteria, in which case, which persons...

Is the conversion different according to the quantity of CO2 people have in their blood or other reasons?

 

[mattyb]

Sorry.... I meant something else when I asked WHY. As you said "CAN convert", does it mean it does not always do it? (or not that quick, or not that much...) Then why it does or does not convert, and according to what criteria, in which case, which persons...

Is the conversion different according to the quantity of CO2 people have in their blood or other reasons?

There are many things. A zinc deficiency will reduce the ability of carbonic anhydrase to do it's job because it is a zinc dependent enzyme. That's a basic one.

Then things like O2, CO2, H+ concentrations will affect this conversion. The list goes on. This is just a basic primer. If you want to read about all the subtleties of acid-base disorders I recommend you start reading a textbook for nephrology and respirology.

 

[mattyb]

Part 2 - The Primary Acid-Base Disorders - Respiratory Acidosis (RAc)

The first thing you have to realize is that Acid Base Disorders are often transient in nature. A person can go in and out of different acid-base states throughout a day, or be biased towards certain acid-base states without explicitly being in one as defined by medical criteria. A person can also be stuck in an acid-base state indefinitely. And lastly, a person can have a mixed acid-base disorder where they have features of several different types of acid-base disorders.

Basics
RAc is easily the most common acid-base disorder I see in our sleep disorder lab. It is defined as a person having an arterial pH below 7.35 and blood CO2 being above ~45 mmHg. In the medical community it is most commonly associated with obesity, sedentary behavior, aging, airborne pollution exposure, COPD, kyphoscoliosis, and tobacco use. If respiratory acidosis is the primary disorder, one the factors listed above will be the most likely culprit.

In the real (non-medical) world, I think one of the biggest causes of transient RAc is office work and high sugar consumption done in conjunction. Glucose, when oxidized, produces more CO2 per unit than fat. This CO2 builds up in the system, and because people often sit all day in a kyphotic position (hunched over) it reduces ventilation capacity, allowing CO2 to quickly build up in the body because the lungs are structurally inhibited from maximal ventilation.

Things like coffee and other stimulants, that stimulate ventilation via adrenaline, can help increase the rate that CO2 is expelled. Other things, like ibuprofen and aspirin can also help by stimulating mitochondrial uncoupling, which increases O2 consumption without increasing CO2 concentration. But these are not proper solutions, and come with their own price in the end. Ultimately the safest and most effective ways to combat RAc is to sit in a good posture, fix any underlying kyphosis or scoliosis, moderate carbohydrate consumption during periods of inactivity, breathing exercises (diaphragmatic breathing, maximal exhalations, wim hof/holotrophic breathing) and exercise or move around frequently (low-intensity cardio is great for this). Keeping a normal bodyweight, not smoking, and limiting exposure to airborne pollutants are obviously essential as well - but for most health nuts on this forum this shouldn't be an issue.

Compensations
Recall the formula CO2 + H2O + H+ -> H2CO3 -> HCO3- + H+

So you can see for every unit of CO2 produced, there is, in the end, an equivalent increase in HC03-. This is a normal sequence that happens spontaneously and almost immediately. But if this process isn't enough to combat the acidity, the kidneys start retaining additional bicarb to help neutralize the acidity. This retention of bicarb can induce metabolic alkalosis (which we'll go over later). So the compensation for respiratory acidosis is metabolic alkalosis.

Obviously this can present some serious problems for people who are only transiently in respiratory acidosis during their work day, but then go off and move around later on. It's a long enough time for there to be compensation from the kidneys, so when ventilation kicks back in, you are just left with metabolic alkalosis.

Inversely, respiratory acidosis can be a compensation for metabolic alkalosis. If a person goes into metabolic alkalosis, this will depress their rate of CO2 ventilation and make them retain more CO2, thereby increasing acidity. Obviously you can see how this could create a vicious cycle for some people who are cycling between resp acidosis -> met alkalosis -> resp acidosis consistently throughout the day because of sit -> move -> sit cycle highlighted by sugar consumption and structural deficits preventing proper ventilation.

Next up is Metabolic Acidosis.

 

[BeLikeWater]

Thank you this is good! You should make themninseparated threads so its easy to follow and question about the issue of the "lesson".

 

[jaa]

Part 2 - The Primary Acid-Base Disorders - Respiratory Acidosis (RAc)

That sounds like me. What type of sleep patterns or disturbances do you typically see in people with RAc and how does one correct it?

 

[mattyb]

Thank you this is good! You should make themninseparated threads so its easy to follow and question about the issue of the "lesson".

I still suck at using the moderating features, but the plan is that once everything is finished I will move all of my posts to a separate thread so it's easy to read through it all in order.

For the time being, I will just keep doing this, and then people can ask me questions along the way, and I can make edits and add in new info if certain things need more clarification based off of questions.

That sounds like me. What type of sleep patterns or disturbances do you typically see in people with RAc and how does one correct it?

Frequent low-level arousals (waking up) throughout the night is the most common. You'll see drowsiness throughout the day, falling asleep easily (in front of TV, while reading, sometimes even while driving, etc.) If it's very severe you may see signs of hypoxia as well - white/purple extremities, poor circulation. Poor exercise tolerance is common. People can develop mood disorders, hypertension, and headaches as well. There are many symptoms, since it is a hypoxic condition the effects are fairly systemic. If the hypoventilation is very severe and persistent you'll see cardiac problems.

Obesity hypoventilation syndrome is the most common cause of RAc in our clinic, and it often happens concurrent to sleep apnea. People with just sleep apnea don't often have severe RAc because their O2 sats drop really low and their CO2 sats often drop alongside it (since we need O2 to make CO2), so they stay "balanced" overall, albeit oxygen deprived. Losing a significant amount of weight is often the primary means of correcting both conditions, while a CPAP or BiPAP is used in the interim to help stabilize the person and because it facilitates weight loss.

If you have respiratory acidosis due to other issues, then the treatment would vary. Lots of potential treatments depending on the cause.

If you find yourself waking up at night frequently for no apparent reason, I would definitely recommend getting a sleep study done. Could be hypoventilation syndrome or sleep apnea causing the arousals.

 

[jaa]

If you find yourself waking up at night frequently for no apparent reason, I would definitely recommend getting a sleep study done. Could be hypoventilation syndrome or sleep apnea causing the arousals.

Thanks for the advice. It's nothing too serious, but I often (3-5 times/week) wake up a sleep cycle too early. I will get a sleep study if the issue persists.

 

[Canari]

So the compensation for respiratory acidosis is metabolic alkalosis.

Is there ALWAYS a compensation?

Obviously this can present some serious problems for people who are only transiently in respiratory acidosis during their work day, but then go off and move around later on. It's a long enough time for there to be compensation from the kidneys, so when ventilation kicks back in, you are just left with metabolic alkalosis.

Is this because kidneys have no time to reverse the trend on their side?

Inversely, respiratory acidosis can be a compensation for metabolic alkalosis.

I am looking forward knowing what is the cause of the metabolic alkalosis.....

Next up is Metabolic Acidosis.

Probably mine, because I have lactate!

What is the primary cause leading to the advise to take HCl? Is it metabolic alkalosis?

 

[mattyb]

Also I gotta start updating this thread again.