BIOCHEM1

Classification of Amino acids, Amino acid Structures and Functions

Proteins:

Carry out virtually all of a cell’s activities:

Enzymes;
Structural;
Mechanical support;
Regulatory functions: hormones ; GF; Gene activators;
Receptors;
Control of gene expression;
Antibodies;
Form blood clots.

Amino Acid composition of Proteins:

21 amino acids;
Common amino acids-one codone in genetic code;
Derived amino acids-enzymatic modification of one of the common amino acids:
(cystine; hydroxyproline, phosphoserine).

Classification of Amino Acids:

Amino acids can be classified based on several criteria:

1. Based on Side Chain (R-group) Properties:

Non-polar (Hydrophobic) Amino Acids: These have side chains that are mostly
hydrocarbons, making them insoluble in water. Examples include alanine,
valine, leucine, isoleucine, phenylalanine, tryptophan, and methionine.
Polar (Hydrophilic) Amino Acids: These have side chains that are polar but
uncharged, making them soluble in water. Examples include serine, threonine,
cysteine, tyrosine, asparagine, and glutamine.

Acidic (Negatively Charged) Amino Acids: These have side chains that are
negatively charged at physiological pH. Examples include aspartic acid
 (aspartate) and glutamic acid (glutamate).
Basic (Positively Charged) Amino Acids: These have side chains that are
positively charged at physiological pH. Examples include lysine, arginine, and
histidine.

1. Based on Nutritional Requirements:

Essential Amino Acids: These cannot be synthesized by the body and must be
obtained from the diet. There are 9 essential amino acids: histidine, isoleucine,
leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine.
Non-essential Amino Acids: These can be synthesized by the body and are not
required to be obtained from the diet. Examples include alanine, asparagine,
aspartic acid, cysteine, glutamic acid, glutamine, glycine, proline, serine, and
tyrosine.
Amino Acid Structures:

All amino acids have a common structure consisting of a central carbon atom (the
alpha carbon) bonded to an amino group (-NH2), a carboxyl group (-COOH), a
hydrogen atom, and a variable side chain (R-group).
Side Chains:

Define the Chemical Nature and Structures

Alkyl group side chains:
Glycine has the simplest structure, with R = H.
Alanine contains a methyl (CH3-) group.
Valine has an isopropyl R group.
The leucine and isoleucine R groups-isobutyl groups.

Aromatic amino acids:

Phenylalanine contains a benzene ring;

Tyrosine a phenol group;
Tryptophan the heterocyclic structure, indole.
In each case the aromatic moiety is attached to the
a-carbon through a methylene (-CH2-) carbon.

Sulfur-containing amino acids:

The cysteine side-chain group is a thiolmethyl (HSCH 2-),

Methionine the side chain is a methyl ethyl thiol ether (CH3SCH2CH 2-).

Hydroxy (alcohol)-containing amino acids:

In serine the side chain is a hydroxymethyl (HOCH 2-).

In threonine an ethanol structure is connected to the a-carbon to produce a
secondary alcohol (CH3-CHOH-CHa-).
Proline:

Unique
Incorporates the a-amino group in its side chain;
Classified as an a-imino acid, since its a-amine is a secondary amine with its a-
nitrogen having two covalent bonds to carbon.
Incorporation of the a-amino nitrogen into a five-member ring constrains the
rotational freedom around the -N-C bond in proline;
Limits proline participation to particular polypeptide chain conformations.

Dicarboxylic-monoamino acids:

Carboxylic group in their side chain;

In aspartate, this group is separated by a methylene carbon (-CH 2-) from the a-
carbon.
In glutamate the group is separated by two methylene (-CH 2-CH 2-) carbon
atoms from the a-carbon.
At physiological pH, these groups are unprotonated and negatively charged.

Glutamine and Asparagine:

Structural analogs of glutamic acid and aspartic acid with their carboxylic acid
side-chain groups amidated.
Unique DNA codons exist for glutamine and asparagine separate from those for
glutamic acid and aspartic acid.
The amide side chains of glutamine and asparagine cannot be protonated and are
uncharged at physiological pH.

Dibasic-monocarboxylic amino acids:

R group contains one or two nitrogen atoms-act as a base by binding a proton.

Lysine-side chain-an N-butyl amine.
Arginine-the side chain-a guanidino group separated from the a-carbon by three
methylene carbon atoms.
Both are protonated at physiological pH (pH-7) and positively charged.
Histidine:
the side chain heterocyclic, imidazole group.

Selenocysteine:

20 amino acids derived from 64 possible triplet codons with 3 codons;

21st-selenocysteine;
Structurally similar to cysteine, but with a selenium atom replacing the sulfur
atom.
Its codon is UGA-identical to the stop codon.
 Within special RNA contexts it will code for selenocysteine;
25 genes;
Antioxidant role.

Amino acids:

To represent sequences of amino acids in proteins, three-letter or one-letter

abbreviations for the common amino acids are used.

Cystine:

Derived amino acid;

formed by the oxidation of two cysteine thiol side chains to form a covalent
disulfide bond.

Amino acid stereoisomerism:

Amino acids also have asymmetric carbon atoms.

With the exception of glycine α‐carbon of amino acids bonds to four different
groups.
Each amino acid can exist in either a D or an L form.
 Synthesis of a protein on a ribosome are always L‐amino acids.

Histones:

Contain basic amino acids

High content of lysine, arginine
Positively charged
Binds negatively charged phosphate backbone DNA

Functions of Amino Acids:

1. Protein Synthesis: Amino acids are the building blocks of proteins. During protein
synthesis, amino acids are linked together via peptide bonds to form polypeptide
chains, which fold into functional proteins.
2. Enzymes and Metabolism: Many enzymes are proteins composed of amino acids.
These enzymes catalyze biochemical reactions essential for metabolism, such as
digestion and energy production.
3. Structural Support: Proteins provide structural support to cells and tissues.
Examples include collagen in connective tissues and keratin in hair and nails.
4. Transport and Storage: Amino acids are involved in the transport and storage of
nutrients and other molecules. For instance, albumin transports fatty acids and
hormones in the bloodstream.
5. Signaling: Amino acids and their derivatives act as signaling molecules in
intercellular communication. Examples include neurotransmitters like serotonin
and hormones like insulin.
6. Immune Function: Some amino acids play roles in immune function, such as
glutamine, which is important for the function of immune cells.
7. Precursors for Biosynthesis: Amino acids serve as precursors for the biosynthesis
of various molecules, including neurotransmitters, hormones, nucleotides, and
creatine.

Clinical Relevance:

Understanding amino acids is crucial in clinical practice for:

Nutritional Assessment: Evaluating amino acid levels in patients to assess

nutritional status or diagnose metabolic disorders.
Therapeutics: Developing treatments targeting amino acid metabolism or
deficiencies.
Disease Mechanisms: Understanding how amino acid imbalances contribute to
diseases such as phenylketonuria or maple syrup urine disease.
Peptides and Proteins:

Enzymatically catalyzed;
Dehydration reaction;
The a-carboxyl group of one amino acid forms a covalent peptide bond with the
a-amino group of another amino acid by elimination of a molecule of water.

Peptide bond:

Can be represented as two resonance isomers;

Structure I- a double bond is located between the carbonyl carbon and carbonyl
oxygen-(C' = O), the carbonyl carbon to nitrogen (C'-N) linkage is a single bond;
In structure II- the carbon to oxygen bond (C'-O-) is a single bond; the bond
between the carbon and nitrogen is a double bond (C' = N):
Negative charge on the oxygen and a positive charge on the nitrogen.
Actual peptide bonds are a resonance hybrid of these two electron isomer
structures;
The carbon to nitrogen bond having a 50% double-bond character.
X-ray diffraction studies confirm this and show the carbonyl carbon to nitrogen
bond length (1.33A) is approximately half way between that of a C'-N single bond
(-1.45A) and a C' = N double bond (-1.25A).
 A consequence of the partial double bond character is that rotation does not
occur about the carbonyl carbon to nitrogen of a peptide bond at physiological
temperatures.
Trans configuration of its oxygen (0) and hydrogen (H) atoms.
The most stable configuration with the two side chains of the adjacent residues
(R and R') also being in trans.
Cis configuration-brings the two side-chain groups to the same side of the C' = N
bond, which is unfavorable because of steric hindrance between the R groups.

Titration of a Monoamino Monocarboxylic Acid:

Leucine has an a -COOH with pKa = 2.4 and an a-NH3+ group with pKa= 9.6.
At pH 1.0 the predominant ionic form(formI) has a charge of+ I and migrates
toward the cathode in an electrical field;
Addition of 0.5 equivalent of base titrates half the a-COOH groups
[COO-]/[COOH]=1;
At a ratio of conjugate base: acid of 1:1, the pH (when the a-COOH is half citrated)
is directly equal to the pKa(COOH).
Addition of 1equiv of base at pH 6.0 completely titrates the a-COOH, no effect on
the a-NH3+.
In the resulting form(II), the negative and positive charges cancel each other and
the net charge is zero.
The zwitterion will not migrate in an electric field.
Further addition of 0.5equiv of base to the zwitterion form (total base added is
1.5 equiv) will half-titrate the a-NH 3+ group;
At this point, the ratio of [NH2]/ [NH3 +]=1, the pH is equal to the value of the pKa
for NH3+;
Addition of a further 0.5equiv of base (total two full equivalents of base)
completely titrates the a-NH3+ group to its base form (a-NH2).
The pH becomes greater than 11,the predominant molecular species has a
negative charge (form III).

PH, Pk Values, Buffers, Buffering

Water and Unique Solvent Properties:

Dissolve a variety of inorganic and organic molecules

Polar- salts are dispersed readily in water;
The attraction of the charged Na+ and Cl- atoms in NaCl is overcome by:
Interaction of Na+ with the negative charge on oxygen atoms of water;
Cl- with the positive charge on hydrogen atoms.
In solution, the individual ions are surrounded by a shell of water.
Nonionic organic molecules containing weakly polar groups are also soluble in
water;
 Sugars and alcohols are readily soluble.
Compounds chat contain both polar and nonpolar groups- amphipathic
molecules- disperse in water if attraction of the polar group for water can
overcome hydrophobic interactions of nonpolar portions of the molecules.
Hydrophobic molecules (lipids) containing long hydrocarbon chains do not
readily disperse as single molecules in water.

Hydrophobic interaction:

When nonpolar compounds are mixed with water, the nonpolar, hydrophobic (“water
fearing”) molecules are forced into aggregates, which minimizes their exposure to the
polar surroundings.

Electrolytes:

Cations (positively charged ions);

Anions (negatively charged ions);
Electrolytes-facilitate conductance of an electrical current;
Sugars or alcohols are nonelectrolytes because they dissolve readily in water but
do not carry a charge or dissociate into charged species;
Salts of alkali metals (e.g.,Li, Na, K) and acids such as hydrochloric and sulfuric at
low concentrations dissociate completely;

Dissociation of Molecules in Water:

If a solution contains a number of different salts (NaC and K2SO4), these

molecules do not exist as such in solution.
Only the dissociated ions (Na+, K+,) are present.
Salts that dissociate completely are referred to as strong electrolytes.
In water , the dissociated anions of organic salts react to some degree with free
protons (H+) from dissociation of water to form the undissociated acid.
Many acids do not dissociate totally;
Establish equilibrium between undissociated and dissociated components.
The degree of dissociation of such an electrolyte depends on the affinity of the
anion for an H+.
There will be more dissociation if the weak dipole forces of water that interact
with the anion and cation are stronger than the electrostatic forces between the
anion and H+.

Weak electrolytes.

In partial dissociation of a weak electrolyte , represented by HA, the

concentration of various species can be determined from the equilibrium
equation.
 Keq is a physical constant, A- represents the dissociated anion;
mol/L or M; millimol/L or mM;
Since the dissociation of an acid increases with increasing temperatures, the Keq
will also increase.
From the dissociation equation, it is apparent that Keq will be a small number if
the degree of dissociation of a substance is small.

Water Is a Weak Electrolyte:

HOH = H+ + OH-
Protons that dissociate interact with oxygens of other water molecules to form
clusters of water molecules-H+(H20)n,
where n has been determined to be from 6 to 27.
This hydration of H+ is often presented as H3O+, the hydronium ion;
At 25°C the value of K for dissociation of water is about 1.8 X 10- 16.
With such a small Keq an extremely small number of water molecules actually
dissociate.

The concentration of water, 55.5 M, is unchanged by the very small dissociation

and is a constant. Therefore , Keq can be rewritten as follows:

K’eq X [H20]=[H+][OH]
Keq X [55.5] is a constant and is termed the ion product of water
In pure water the concentration of H+ equals OH-.
If the [H+] is increased, as occurs on addition of an acid, a decrease of [OH-] must
occur in order to satisfy the equilibrium relationship of water.

pH and pKa Values:

pH:
 pH is a measure of the acidity or basicity of a solution and is defined as the negative
logarithm of the hydrogen ion concentration ([H+]) in moles per liter.
pH scale ranges from 0 to 14, where pH 7 is neutral (equal concentrations of [H+] and
[OH-]), pH less than 7 is acidic (higher [H+]), and pH greater than 7 is basic or alkaline
(lower [H+]).
pH = –log[H+]

The isoelectric pH:

It is useful to calculate the pH at which an amino acid is in it zwitterion form.

This pH is the isoelectric pH for the molecule, represented as pl.
The pK value is a constant for a compound at a particular ionic strength and
temperature.
For simple amino acid molecules, leucine, pl is calculated as the average of the
two pK'a values that regulate the boundaries of the zwitterion form:

pl=pK’aCOOH+pK’aNH3+/2=2.4+9.6/2=6.0
General Relationship between Charge Properties of Amino Acids and Proteins, and
pH:

As proteins are complex polyelectrolytes that contain many ionizable groups that
regulate the zwitterion form, calculation of a protein's isoelectric pH from its
multiple acid pKa values utilizing the Henderson - Hasselbalch relationship is
difficult.
pI values of proteins are experimentally measured by determining the pH value
at which the protein does not move in an electric field.
pH>pl-protein charge negative
pH<pl-protein charge positive

Ionic Form of an Amino Acid or Protein Can Be Determined at a Given pH:

The ionic form of the molecule can be calculated at a given pH;

pH=pKa+log [conjugate base]/[conjugate acid]

or
pH-pKa=log [conjugated base]/[conjugated acid]
Equation shows the change in ionization state and charge of a molecule with pH.
Some enzymes require a histidine imidazole in its base form for catalytic activity.
If the pK'a of this histidine is 6.0, at pH 6.0 one-half of the enzyme molecules are
in the active base (imidazole) form and one-half of the enzyme molecules are in
 the inactive acid (imidazolium) form.
The enzyme exhibits 50% of its potential activity.
pH 7.0, the ratio of [irnidazole]/[imidazolium] is 10:1 91 % of its maximum
potential activity.

Acid and Base:

An acid - a proton donor;

A base - a proton acceptor;
HCl and H2SO4 - strong acids, because they dissociate totally, releasing protons.
OH- a strong base, because it readily associates with available protons to form
H2O.
When a strong acid and OH- are combined, H+ from the acid and OH- interact
essentially totally and neutralize each other.
Anions produced when strong acids dissociate, such as Cl- from HCI, are not
bases because they do not reassociate with protons in dilute solution.

Dissociation:

Most organic acids found in biological systems dissociate partially and are
classified as weak acids.
HA = A- + H+
The anion formed in this dissociation is a base because it can accept a proton to
reform the acid;
A weak acid and its base (anion) formed on dissociation are referred to as a
conjugate pair.
The ammonium ion (NH4+) is a weak acid because it dissociates to yield H+ and
uncharged ammonia (NH3), a conjugate base;

Keq for acid:

The tendency of a conjugate acid to release H+ can be assessed from the Keq.
The smaller the value of Keq, the less the tendency to give up a proton and the
weaker the acid.
The larger the value of Keq the greater the tendency to dissociate and the
stronger the acid.
Water is a very weak acid with a Keq of 1.8 X 10- 16 at 25°C.
A convenient method of stating the Keq is in the form of pK', defined as:

pK’=log 1/K’eq
pKa:
 pKa is the negative logarithm of the acid dissociation constant (Ka), which
measures the strength of an acid in solution.
Lower pKa indicates a stronger acid (more readily dissociates to release H+ ions),
and higher pKa indicates a weaker acid (less readily dissociates).
log acid dissociation constant
HA = A- + H+;
pH = pKa + log [A- ] [HA] ;
pKa = pH - log [A- ] [HA].

pK and Keq:

The acid dissociation constant (Ka) of a solution is pKa, the negative base-10
logarithm.
The pKa value is one method of determining an acid's strength.
A lower pKa value denotes a more powerful acid.
Note the similarity of this definition with that of pH; as with pH and [H+], the
relationship between pK' and Keq is an inverse one.
The smaller Keq the larger pK'.

Charge and Chemical properties of Amino Acids and Proteins:

In forming its conjugate base-the acid form releases a proton.

In reverse, the base form associates with a proton to form the respective acid.
The dissociation of an acid is characterized by an acid dissociation constant:

pK’a=log(1/K’a)
pK'a is affected by the polarity of the environment; absence or presence of water,
and the potential for hydrogen bond formation.
In addition, acid groups (a-COOH or a-NH3 +) at the ends of polypeptides typically
have a lower pKa value than the same types of acid groups in the side chain.
The amino acids whose R groups contain nitrogen atoms (Lys ;Arg) are the basic
amino acids, since their side chains have relatively high pK’a values and function
as bases at physiological pH.
They are usually in their acid form and are positively charged at physiological pH.
Amino acids whose side chains contain a carboxylic acid group have relatively low
pK’a values that easily lose their protons and are acidic amino acids.
They are predominantly in their unprotonated forms and negatively charged at
physiological pH.

pK~ Values for the Common Acid Groups in Proteins:

pK'a values for each acid group, as the actual pK’a depends on the environment in
which an acid group is placed.
 When a positively charged ammonium group (-NH3 +) is placed near a negatively
charged group in a protein, the negative charge stabilizes the positively charged
acid for making it more difficult to dissociate its proton.
The pK'a of the-NH3+ will have a higher value than normal for an ammonium
group in the absence of a nearby negative-charge stabilization.

The Henderson–Hasselbalch equation:

One way to determine the pH of a buffer is by using the Henderson–Hasselbalch

equation, which is:

In this equation, [HA] and [A⁻] refer to the equilibrium concentrations of the
conjugate acid–base pair used to create the buffer solution.
When [HA] = [A⁻], the solution pH is equal to the pKₐ of the acid.
provides a relationship between the pH of acids (in aqueous solutions) and
their pKa (acid dissociation constant).
If we know pH of the buffer solution, we can use this equation to know the
relative concentrations of weak acid and its conjugate base.

1. [HA]=[A-] pH=pKa
2. [HA]>[A-] pH<pKa
3. [HA]<[A-] pH>pKa
Buffers and Buffering Systems:

Acid-Base Equilibrium:

CO2 + H2O - HCO3- + H+;

CO2-Maintained by lungs
HCO3-Maintained by kidneys/Metobolism
H+-Determines pH
Acid-Base Equilibrium

Normal HCO3-=22–26 mEq/L;

Normal pCO2=35–45 mmHg;
Normal pH=7.35-7.45.

Buffers:

Buffers are solutions that resist changes in pH when acids or bases are added to
them. They consist of a weak acid and its conjugate base (or a weak base and its
conjugate acid).
The buffer capacity is the ability of a buffer solution to resist changes in pH upon
addition of acid or base.
Extracellular Buffers:
Carbonic acid/Bicarbonate (H2CO3/HCO3-)
Haemoglobin
Intracellular Buffers:
Proteins
Phosphoric acid/hydrogen phosphate (H3PO4/H2PO4-+ HPO42-)
Henderson-Hasselbalch equation:
pH = 6.1 + log([HCO3-]/0.03 pCO2)
Buffering Systems:

1. Carbonic Acid-Bicarbonate Buffer System:

Found in blood plasma and maintains blood pH.
Involves carbonic acid (H2CO3) as a weak acid and bicarbonate ion (HCO3-) as
its conjugate base.
Helps regulate pH by adjusting the ratio of H2CO3 to HCO3- in response to
changes in [H+] or [OH-].
2. Phosphate Buffer System:
Found in intracellular fluid and urine.
Involves dihydrogen phosphate ion (H2PO4-) as a weak acid and hydrogen
phosphate ion (HPO4^2-) as its conjugate base.
3. Protein Buffer System:
Proteins contain ionizable groups (e.g., amino and carboxyl groups) that can
act as buffers.
Important in intracellular fluids and blood plasma.

Regulation by Organs:

Equilibrium with plasma

High buffer capacity
Haemoglobin–main buffer for CO2
 Excretion of CO2 by alveolar ventilation: minimally 12,000 mmol/day
Reabsorption of filtered bicarbonate: 4,000 to 5,000 mmol/day
Excretion of the fixed acids (acid anion and associated H+): about 100 mmol/day-
Kidneys
Liver-CO2 production from complete oxidation of substrates
20% of the body’s daily production
Metabolism of organic acid anions
such as lactate, ketones and amino acids
Metabolism of ammonium
conversion of NH4+ to urea in the liver results in an equivalent production of
H+
Production of plasma proteins
esp. albumin contributing to the anion gap
Bone inorganic matrix consists of hydroxyapatite crystals (Ca10(PO4)6(OH)2]
bone can take up H+ in exchange for Ca2+, Na+ and K+ (ionic exchange) or
release of HCO3-, CO3- or HPO42-

Importance in Physiology:

Acid-Base Balance: Buffers play a critical role in maintaining the body's acid-base
balance, which is essential for normal physiological function.
Respiratory and Renal Regulation: Respiratory system regulates CO2 levels
(which affects pH) while kidneys regulate H+ and HCO3- concentrations to
maintain pH homeostasis.
Clinical Applications: Understanding buffers is crucial for interpreting blood gas
analysis, diagnosing acid-base disorders (e.g., metabolic acidosis or alkalosis), and
prescribing treatments (e.g., administering bicarbonate in acidosis).

Abnormal Medical Conditions:

Blood pH of 7.35 - 7.45 – Normal;

Below 7.35 – acidosis;
Above 7.45 – alkalosis;
Acidosis/alkalosis
-Disorder altering H+ levels
Acidemia/alkalemia
Presence of high or low pH in bloodstream
Can have acidosis without acidemia if mixed disorder
i.e. acidosis + alkalosis at same time
A metabolic acidosis-excess production of acids-diabetes, hypoxemia;
loss of HCO3- severe diarrhea, uremia, and chronic renal diseases;
A respiratory acidosis-retention of CO2- fluids in the lungs, emphysema, asthma;
restriction in breathing as in trauma, poliomyelitis, severe obesity;
Metabolic alkalosis-retention of HCO3- and ingestion of bases;
 A respiratory alkalosis–hyperventilation(hysteria/tenseness,overdose of some
drugs (e.g., salicylate), fever).

Acidosis Symptoms:

Hyperventilation
Depression of myocardial contractility
Cerebral vasodilation
Increased cerebral blood flow; Increase ICP
CNS depression (very high CO2 levels)
Hyperkalemia- High H+ shifts into cells in exchange for K+
Shift in oxyhemoglobin dissociation curve
Bohr effect
↓ pH leads to hemoglobin releasing more oxygen

Alkalosis Symptoms:

Inhibition of respiratory drive

Depression myocardial contractility
Cerebral vasoconstriction
Decrease in cerebral blood flow
Hypokalemia
Shift in oxyhemoglobin dissociation curve

Acid-Base Problems:

1. Check the pH:

pH < 7.35 = acidosis

pH > 7.45 = alkalosis

2. Check the HCO3- and pCO2:

HCO3 from venipuncture; normal 22-28 mEq/L

pCO2 from ABG; normal 35-45mmHg

3. Determine acid-base disorder:

Acidosis + ↓ HCO3- = metabolic acidosis

Acidosis + ↑pCO2 = respiratory acidosis
Alkalosis + ↑HCO3 - = metabolic alkalosis
Alkalosis+ ↓ pCO2 = respiratory alkalosis

Compensatory Changes:

↓ HCO3 - = metabolic acidosis

Compensation = ↓pCO2
 ↑ HCO3 - = metabolic alkalosis
Compensation = ↑pCO2
↑pCO2 = respiratory acidosis
Compensation = ↑ HCO3-
↓pCO2 = respiratory alkalosis
Compensation = ↓ HCO3-

Compensation:

Respiratory:

Hyperventilation
Blows off CO2
Plasma CO2 level falls Less
H+ in blood
pH rises
Hypoventilation
Retains CO2
Plasma CO2 level rises
More H+ in blood
pH falls

Renal:

Acidosis
Excess H+ filtered/secreted into nephron
Bicarbonate reabsorbed
Urinary buffers excreted
HPO4 2- excreted as H2PO4- (phosphate)
NH3 excreted as NH4+ (ammonium)
These bind H+ (buffers)
Prevent severe drops in pH
Alkalosis-reverse

Mixed Disorders:

Two disorders at same time

Metabolic acidosis AND respiratory alkalosis/acidosis
Metabolic acidosis AND metabolic alkalosis
Two metabolic acidoses
Occurs in many pathologic states
To uncover, determine “expected” response
Expected HCO3- for respiratory disorder
Expected CO2 for metabolic disorder
Use renal formulas to determine expected response
 If actual ≠ expected → 2nd disorder present

Compensation Formulas:

Metabolic Acidosis Compensation

Compensatory respiratory alkalosis (↓ pCO2)
Hyperventilation
Winter’s Formula: tells you expected pCO2
If actual CO2 ≠ expected, mixed disorder
pC02=1.5(HCO3-)+8/-2
pCO2=1.5 (HC03-)+8+/-2

Acid-Base Disorders:

Respiratory Alkalosis:
↓pCO2; pH>7.45
Caused by hyperventilation:
Pain;
Early high altitude exposure;
Early aspirin overdose.

High Altitude:

Lower atmospheric pressure

Lower pO2
Hypoxia → hyperventilation
↓pCO2 → respiratory alkalosis (pH rises)
After 24-48hrs, kidneys will excrete HCO3-
pH will fall back toward normal
Ventilation rate will decrease
Acetazolamide can augment excretion HCO3-

Aspirin Overdose:

Two acid-base disorders

Shortly after ingestion: respiratory alkalosis
Salicylates stimulate medulla
Hyperventilation
Hours after ingestion: AG metabolic acidosis
Salicylates ↓lipolysis, uncouple oxidative phosphorylation
Inhibits citric acid cycle
Accumulation of pyruvate, lactate, ketoacids
pH - Variable due to mixed disorder (Acidotic, alkalotic, normal)
CO2-Low due to hyperventilation
HCO3- Low due to acidosis
Respiratory Acidosis:

↑pCO2 ; pH<7.35
Caused by hypoventilation:
Lung disease (COPD, PNA, Asthma)
Narcotics
Respiratory muscle weakness
Myasthenia gravis
Amyotrophic lateral sclerosis
Guillain-Barré syndrome
Muscular dystrophy

Hypercapnia:

Hypercapnia can affect CNS system

Most patients with acute ↑CO2 are agitated
Some have depressed consciousness (CO2 narcosis)
Δ mental status in patient with respiratory disease:
Consider high CO2
Check ABG
If CO2 high → ventilation

Metabolic Alkalosis:

↑HCO3 -; pH>7.45
Contraction alkalosis
Hypokalemia
Diuretics
Vomiting
Hyperaldosteronism
Antacid use

Loss of H+ from the body or gain of HCO3-

Contraction Alkalosis:

↓ECV → Renin-Angiotensin-Aldosterone activation

↑H+ secretion proximal tubule (due to AII)
↑ HCO3 - resorption proximal tubule (due to ↑H+ secretion)
↑H+ secretion collecting duct (due to aldosterone)

Hypokalemia:

K+ can exchange with H+ to shifts in and out of cells

When ↓ K+ → shift K+ out of cells → H+ in of cells
 Hypokalemia → alkalosis (vice versa)

Diuretics:

Loop and thiazide diuretics → metabolic alkalosis

Volume contraction
Hypokalemia
↑Na/H2O delivery to distal nephron ↑K+/H+ secretion

Bartter and Gitelman Syndromes:

Congenital disorders
Bartter
Dysfunction N-K-2Cl pump ascending limb
Similar to loop diuretic
Gitelman
Dysfunction of Na-Cl transport in distal tubule
Similar to thiazide diuretic
Both cause hypokalemia/alkalosis

Vomiting:

Loss of volume → contraction alkalosis

Loss of HCl
↑ production HCl
HCO3 - generated during production
Loss of K+
Urinary chloride is low (<20)

Urinary Chloride:

Useful in metabolic alkalosis unknown cause

Low (20) in many other causes alkalosis
Classic scenario:
Young woman with unexplained metabolic alkalosis
Urinary Cl is low
Diagnosis: surreptitious vomiting

Surreptitious Diuretics:

Intermittent use for weight loss, elimination of edema

Can cause metabolic alkalosis
Widely varying urinary chloride levels
Initially may cause high urinary chloride
Urinary chloride falls to low levels when effects wane
Key test: diuretic screen
Hyperaldosteronism:

Adrenal overproduction aldosterone

Adrenal hyperplasia
Adrenal adenoma (Conn’s syndrome)
↑ K+/H+ secretion
Hypokalemia
Metabolic alkalosis
Resistant hypertension

Antacid Use:

Milk-alkali syndrome:
Excessive intake of: Calcium; Alkali (base)
Usually calcium carbonate and/or milk
Often taken for dyspepsia
Hypercalcemia:
Inhibition Na-K-2Cl in TAL
Blockade (ADH)-dependent water reabsorption collecting duct
Results in volume contraction
Contraction + alkali = metabolic alkalosis

Metabolic Alkalosis:

Keys to Diagnosis:

History’
Fluid status
Volume depleted: vomiting or GI losses;
Urinary chloride
Low in surreptitious vomiting.
IV Fluid Administration
Resolves most forms of metabolic alkalosis:
“Fluid responsive”
Diuretics
Vomiting
Contraction alkalosis
Exceptions are hyperaldosteronism, hypokalemia .

Metabolic Acidosis:

Most complex set of acid-base disorders

Etiology determined by anion gap:

The Anion Gap:

Positive charged ions–negative charged ions = gap

Positive charged = Na (don’t count K+)
Negative charged = Cl- + HCO3–
Anion Gap = Na – (Cl- + HCO3 -)
Normal < 12 +/- 4
Results from unmeasured ions
Cations: Ca2+, Mg2+, other minerals
Anions: proteins (albumin), phosphates, sulfates
A low anion gap can be caused by hypoalbuminemia
Also caused by multiple myeloma:
IgG is cationic (+)
Will lower measured (+) ions or increase measured (-) ions

Why Does the Anion Gap Matters?

Acidosis from primary loss of HCO3–

Body compensates with retention of Cl-
AG = Na+ – (Cl- + HCO3 -)
Normal anion gap
Acidosis from primary retention of acid
i.e. ketoacids, lactic acid
HCO3- falls without rise in Cl-
Rise in A- to compensate for fall in HCO3-
 AG = Na+ – (Cl- + HCO3 -)
Result is ↑AG
When HCO3 - ↓ something negative must ↑
This maintain balance of (-) and (+) charges
In normal AG → Cl- rises
In high AG → Unmeasured acids rise

Winter’s Formula:

Acidosis: compensatory respiratory alkalosis (↓ pCO2)

Hyperventilation
Winter’s Formula tells you expected ↓pCO2
If actual CO2 ≠ expected, mixed disorder
Check Winter’s formula for all metabolic acidoses:

pCO2=1.5 (HCO3-) + 8 + / -2
The Delta-Delta:

Anion gap ↑ should be similar to HCO3 - ↓

ΔAG = AG – 12
ΔHCO3 - = 24 – [HCO3 - ]
Ratio ΔAG/ Δ HCO3 - assesses for 2° acid-base disorder
Used to check for 2° metabolic acid-base disorder
Winter’s formula assesses for 2° respiratory disorder

ΔΔ=ΔAG/ΔHCO3-
Consider a patient with pH=7.21 (acidosis)
HCO3 - = 12, Na+ = 150, Cl- = 96
Increased anion gap of 42
Delta AG = 42 - 12 = 30
Delta HCO3 - = 24 – 12 = 12
Delta-Delta = 30/12 = 2.5
HCO3 - is too high
Alkalosis or prior resp. acidosis

Non-AG Metabolic Acidosis:

Diarrhea
Lose HCO3- in stool
Acetazolamide
Blocks formation and resorption HCO3–
 Spironolactone/Addison’s disease
Loss of aldosterone effects
Cannot excrete H+ effectively
Body retains H+
Saline infusion
↓renin-angiotensin-aldosterone activity
↓ H+ excretion
Hyperalimentation
Metabolism → ↑HCl
Lowers pH
Renal tubular acidosis

Anion Gap Metabolic Acidosis:

Anion Gap = Na – (Cl- +HC03-)

HCO3- will be low (metabolic acidosis)
Some other (-) substance must ↑ to balance
Other substance is not Cl-
Other substance is “unmeasured anion”
Something with (-) charge that is NOT chloride

Methanol:

Metabolized to formic acid

Central nervous system poison
Visual loss, coma
Found in antifreeze, de-icing solutions, windshield wiper fluid, solvents, cleaners,
fuels, industrial products.

Classic scenario:

Suspected ingestion (accidental, suicide, alcoholic)

Confusion
Visual symptoms
High AG metabolic acidosis

Treatment:

Inhibit alcohol dehydrogenase

Blocks bioactivation of parent alcohol to toxic metabolite
Fomepizole (Antizol)
Ethanol

Ethylene Glycol:

Metabolized to glycolate and oxalate

 Both kidney toxins (slow excretion)
Glycolate: toxic to renal tubules
Oxalate: precipitates calcium oxylate crystals in tubules
Also found in antifreeze, solvents, cleaners, etc.

Classic Scenario:

Flank pain, oliguria, anorexia (acute renal failure)

High AG metabolic acidosis

Treatment:

Inhibit alcohol dehydrogenase

Fomepizole (Antizol)
Ethanol

Uremia:

Advanced kidney disease

Early kidney disease can have non-AG acidosis
Reduction in H+ excretion (loss of tubule function)
Increase in HCO3- excretion
Cl- retained to balance charge (normal AG)
Kidneys cannot excrete organic acids
Retention of phosphates, sulfates, urate, others
Increased anion gap acidosis

Diabetic Ketoacidosis (DKA):

Occurs in type I diabetics

Insulin requirements rise → cannot be met
Often triggered by infection
Fatty acid metabolism → ketone bodies
β-hydroxybutyrate, acetoacetate
Polyuria, polydipsia (↑glucose → diuresis)
Abdominal pain, nausea, vomiting
Kussmaul respirations:
Deep, rapid breathing
From acidosis

High AG metabolic acidosis from ketones

Treatment:

Insulin (lower glucose)

IV fluids (hydration)
Potassium