Renal tubular acidosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Differentiating Renal tubular acidosis from other diseases

Category	Disease		Mechanism			Clinical								Paraclinical																		Gold standard diagnosis	Other findings
						Symptoms				Signs				Lab data
						Symptoms				Signs				ABG			CBC		Chemistry								Renal		U/A
			↑ acid production	Loss of bicarbonate	↓ renal acid excretion	Fever	N/V	Diarrhea	Dyspnea	Toxic/ill	BP	Dehydration	Level of consciousness	HCO₃⁻	paCO₂	O₂	WBC	Hb	BS	Cl⁻	K⁺	Na⁺	Ketones	Lactic acid	Serum AG^[1]	Osmolar gap^[2]	Bun	Cr	Urine pH	Urine AG	Urine ketone
Ketoacidosis	Diabetic ketoacidosis^[3]		+	−	−	+	+	+	+	+	↓	+	↓	↓	↓	Nl to ↓	↑	Nl to ↑	↑↑	Nl	↑	↓	↑	↑	↑	↑	Nl to ↑	Nl	↓	+	+	Clinical + hyperglycemia + ketosis	Labs might show elevated K⁺ even in K⁺ depletion due to extravasation of intracellular K+ in exchanged with extracellular H⁺
	Starvation^[4]		+	−	−	−	+	−	−	+	↓	+	↓	↓	↓	Nl	Nl	Nl	Nl to ↓	Nl	↓	↓	↑	Nl	↑	Nl	Nl	Nl	Nl	+	−	Clinical manifestation	Refeeding syndrome may occur during or after treatment
	Alcoholic ketoacidosis (Ethanol)^[5]		+	−	−	−	+	±	−	+	↓ ↑	+	Agitated	↓	↓	↓	Nl to ↑	Nl to ↑	↓ Nl ↑	Nl	↓	↓	↑↑	↑	↑	↑↑	↑	Nl	↓	+	+	Clinical manifestation + ketosis	Chronic alcohol abuse Zero or low alcohol level
Systemic	Sepsis^[6]		+	−	−	+	+	−	+	+	↓ ↑	+	↓	↓	↓	Nl to ↓	↑	Nl	Nl	Nl	↑	↓	Nl	Nl to ↑	Nl	Nl	↑	↑	Nl	−	−	Clinical manifestation and lab finding	Not applicable
	Ischemia^[7]		+	−	−	−	+	−	+	+	↓	+	−	↓	↓ ↑	Nl to ↓	Nl to ↑	Nl	Nl	Nl	↑	↓	Nl	Nl to ↑	Nl	Nl	Nl to ↑	Nl to ↑	Nl	−	−	Clinical manifestation and lab finding	Not applicable
	Lactic acidosis^[8]		+	−	−	±	+	−	−	+	↓ ↑	±	Agitated	↓	↓	↓	Nl to ↑	↓	Nl	Nl	Nl	Nl	Nl	↑	↑	↑	Nl or ↑	Nl	↓	−	−	Clinical manifestation and lab finding	Not applicable
Renal	Uremia^[9]		−	−	+	+	+	−	−	+	↓ ↑	±	↓	↓	↓	Nl to ↓	↑	↓	Nl	Nl	↑	↑	Nl	Nl	↑	↑	↑	↑	↓	+	−	Clinical manifestation and lab finding	May lead to pericarditis
	Renal failure^[10]		−	−	+	−	+	−	−	+	↓	+	↓	↓	↓	Nl to ↓	↑	↓	Nl	↑	↑	↓	Nl	Nl	↑	↑	↑	↑	↓	−	−	Renal function test	Not applicable
	Renal tubular acidosis^[11]	Type I^[12]	−	−	+	±	±	−	−	−	↓ ↑	−	−	↓	↓	Nl	Nl	Nl	Nl	↑	↓	↓	Nl	Nl	Nl	Nl	↑	↑	↑	+	−	Clinical manifestation and lab finding	Associated with autoimmune diseases Growth retardation in children
		Type II	−	+	−	±	±	−	−	−	↓ ↑	−	−	↓	↓	Nl	Nl	Nl	Nl	↑	↓	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	−	−	Clinical manifestation and lab finding	Not applicable
		Type IV	−	−	+	±	±	±	−	−	↓	−	−	↓	↓	Nl	Nl	Nl	Nl	↑	↑	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	+	−	Clinical manifestation and lab finding	Hypoaldosteronism
Heart	Heart failure^[13]		+	+	−	−	±	−	+	+	↓ ↑	+	−	↓	↓ ↑	↓	Nl	Nl	Nl	Nl	↓	↓	Nl	Nl	Nl	Nl	Nl to ↑	Nl to ↑	Nl	−	−	Clinical manifestation+ echocardiogram	Hypoalbuminemia Elevated serum natriuretic peptide
Heart	Myocardial infarction^[14]		+	−	−	−	+	−	+	+	↓ ↑	−	↓	↓	↓ ↑	Nl to ↓	Nl to ↑	Nl	Nl	Nl	↑	↓	Nl	↑	Nl	Nl	Nl to ↑	Nl to ↑	Nl	−	−	Clinical manifestation + ECG	Not applicable
GI	Diarrhea^[15]		−	+	−	±	+	+	−	+	↓	+	May be lethargic	↓	↓	Nl	Nl	↓	↓	↑	↑	Nl	Nl	Nl	Nl	Nl	↑	Nl	Nl	−	−	Stool exam	Not applicable
	Hyperalimentation^[16]		+	+	−	−	−	+	−	−	Nl	−	−	↓	↓	Nl	Nl	↓	Nl	↑	↑	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	−	−	Clinical manifestation	Not applicable
	Liver failure^[17]		−	+	−	−	+	+	−	+	↓	+	Confused	↓	↓	Nl	Nl	↓	↓ ↑	↑	↓	↓	Nl	Nl	Nl	Nl	Nl	Nl	Nl	−	−	Liver biopsy	Not applicable
Endocrine	Hyperparathyroidism^[18]		−	+	+	−	+	−	−	−	Nl	+	Confused	↓	↓	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl to ↑	Nl	Nl	−	−	PTH level	Not applicable
Endocrine	Addison's disease^[19]		−	+	−	−	+	+	−	−	↓	+	Irritable	↓	↓	Nl	Nl	Nl	↓	Nl	↑	↓	Nl	Nl	Nl	Nl	Nl	Nl	Nl	−	−	Hormone level	Weakness Hyperpigmentation Adrenal Crisis

References

↑ Brubaker RH, Meseeha M. High Anion Gap Metabolic Acidosis. [Updated 2017 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448090/
↑ Kraut JA, Xing SX (September 2011). "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". Am. J. Kidney Dis. 58 (3): 480–4. doi:10.1053/j.ajkd.2011.05.018. PMID 21794966.
↑ Wolfsdorf, Joseph I; Allgrove, Jeremy; Craig, Maria E; Edge, Julie; Glaser, Nicole; Jain, Vandana; Lee, Warren WR; Mungai, Lucy NW; Rosenbloom, Arlan L; Sperling, Mark A; Hanas, Ragnar (2014). "Diabetic ketoacidosis and hyperglycemic hyperosmolar state". Pediatric Diabetes. 15 (S20): 154–179. doi:10.1111/pedi.12165. ISSN 1399-543X.
↑ Mostert M, Bonavia A (October 2016). "Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period". Am J Case Rep. 17: 755–758. PMC 5070574. PMID 27752032.
↑ Howard RD, Bokhari S. PMID 28613672. Vancouver style error: initials (help); Missing or empty |title= (help)
↑ Ganesh K, Sharma RN, Varghese J, Pillai MG (2016). "A profile of metabolic acidosis in patients with sepsis in an Intensive Care Unit setting". Int J Crit Illn Inj Sci. 6 (4): 178–181. doi:10.4103/2229-5151.195417. PMC 5225760. PMID 28149822.
↑ Kimmoun, Antoine; Novy, Emmanuel; Auchet, Thomas; Ducrocq, Nicolas; Levy, Bruno (2015). "Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside". Critical Care. 19 (1). doi:10.1186/s13054-015-0896-7. ISSN 1364-8535.
↑ Kraut, Jeffrey A.; Ingelfinger, Julie R.; Madias, Nicolaos E. (2014). "Lactic Acidosis". New England Journal of Medicine. 371 (24): 2309–2319. doi:10.1056/NEJMra1309483. ISSN 0028-4793.
↑ Brown, Denver; Melamed, Michal L. (2018). "New Frontiers in Treating Uremic Metabolic Acidosis". Clinical Journal of the American Society of Nephrology. 13 (1): 4–5. doi:10.2215/CJN.11771017. ISSN 1555-9041.
↑ Kraut, Jeffrey A.; Madias, Nicolaos E. (2016). "Metabolic Acidosis of CKD: An Update". American Journal of Kidney Diseases. 67 (2): 307–317. doi:10.1053/j.ajkd.2015.08.028. ISSN 0272-6386.
↑ Gil-Peña, Helena; Mejía, Natalia; Santos, Fernando (2014). "Renal Tubular Acidosis". The Journal of Pediatrics. 164 (4): 691–698.e1. doi:10.1016/j.jpeds.2013.10.085. ISSN 0022-3476.
↑ Hemstreet, Brian A (2004). "Antimicrobial-Associated Renal Tubular Acidosis". Annals of Pharmacotherapy. 38 (6): 1031–1038. doi:10.1345/aph.1D573. ISSN 1060-0280.
↑ Park, Jin Joo; Choi, Dong-Ju; Yoon, Chang-Hwan; Oh, Il-Young; Lee, Ju Hyun; Ahn, Soyeon; Yoo, Byung-Su; Kang, Seok-Min; Kim, Jae-Joong; Baek, Sang-Hong; Cho, Myeong-Chan; Jeon, Eun-Seok; Chae, Shung Chull; Ryu, Kyu-Hyung; Oh, Byung-Hee (2015). "The prognostic value of arterial blood gas analysis in high-risk acute heart failure patients: an analysis of the Korean Heart Failure (KorHF) registry". European Journal of Heart Failure. 17 (6): 601–611. doi:10.1002/ejhf.276. ISSN 1388-9842.
↑ Mann, Sarah; Bajulaiye, Akinyemi; Sturgeon, Kathleen; Sabri, Abdelkarim; Muthukumaran, Geetha; Libonati, Joseph R. (2014). "Effects of acute angiotensin II on ischemia reperfusion injury following myocardial infarction". Journal of the Renin-Angiotensin-Aldosterone System. 16 (1): 13–22. doi:10.1177/1470320314554963. ISSN 1470-3203.
↑ Guerrant, R. L.; Van Gilder, T.; Steiner, T. S.; Thielman, N. M.; Slutsker, L.; Tauxe, R. V.; Hennessy, T.; Griffin, P. M.; DuPont, H.; Bradley Sack, R.; Tarr, P.; Neill, M.; Nachamkin, I.; Reller, L. B.; Osterholm, M. T.; Bennish, M. L.; Pickering, L. K. (2001). "Practice Guidelines for the Management of Infectious Diarrhea". Clinical Infectious Diseases. 32 (3): 331–351. doi:10.1086/318514. ISSN 1058-4838.
↑ Erlingsson, Styrbjörn; Herard, Sebastian; Dahlqvist Leinhard, Olof; Lindström, Torbjörb; Länne, Toste; Borga, Magnus; Nystrom, Fredrik H. (2009). "Men develop more intraabdominal obesity and signs of the metabolic syndrome after hyperalimentation than women". Metabolism. 58 (7): 995–1001. doi:10.1016/j.metabol.2009.02.028. ISSN 0026-0495.
↑ Lange, Christian M.; Bojunga, Jörg; Hofmann, Wolf Peter; Wunder, Katrin; Mihm, Ulrike; Zeuzem, Stefan; Sarrazin, Christoph (2009). "Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function". Hepatology. 50 (6): 2001–2006. doi:10.1002/hep.23346. ISSN 0270-9139.
↑ Bilezikian, John P.; Potts, John T.; Fuleihan, Ghada El-Hajj; Kleerekoper, Michael; Neer, Robert; Peacock, Munro; Rastad, Jonas; Silverberg, Shonni J.; Udelsman, Robert; Wells, Samuel A. (2002). "Summary Statement from a Workshop on Asymptomatic Primary Hyperparathyroidism: A Perspective for the 21st Century". The Journal of Clinical Endocrinology & Metabolism. 87 (12): 5353–5361. doi:10.1210/jc.2002-021370. ISSN 0021-972X.
↑ Ten, Svetlana; New, Maria; Maclaren, Noel (2001). "Addison's Disease 2001". The Journal of Clinical Endocrinology & Metabolism. 86 (7): 2909–2922. doi:10.1210/jcem.86.7.7636. ISSN 0021-972X.

[1] Brubaker RH, Meseeha M. High Anion Gap Metabolic Acidosis. [Updated 2017 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448090/

[pmid217949663-2] Kraut JA, Xing SX (September 2011). "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". Am. J. Kidney Dis. 58 (3): 480–4. doi:10.1053/j.ajkd.2011.05.018. PMID 21794966.

[WolfsdorfAllgrove2014-3] Wolfsdorf, Joseph I; Allgrove, Jeremy; Craig, Maria E; Edge, Julie; Glaser, Nicole; Jain, Vandana; Lee, Warren WR; Mungai, Lucy NW; Rosenbloom, Arlan L; Sperling, Mark A; Hanas, Ragnar (2014). "Diabetic ketoacidosis and hyperglycemic hyperosmolar state". Pediatric Diabetes. 15 (S20): 154–179. doi:10.1111/pedi.12165. ISSN 1399-543X.

[pmid27752032-4] Mostert M, Bonavia A (October 2016). "Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period". Am J Case Rep. 17: 755–758. PMC 5070574. PMID 27752032.

[pmid28613672-5] Howard RD, Bokhari S. PMID 28613672. Vancouver style error: initials (help); Missing or empty |title= (help)

[pmid28149822-6] Ganesh K, Sharma RN, Varghese J, Pillai MG (2016). "A profile of metabolic acidosis in patients with sepsis in an Intensive Care Unit setting". Int J Crit Illn Inj Sci. 6 (4): 178–181. doi:10.4103/2229-5151.195417. PMC 5225760. PMID 28149822.

[KimmounNovy2015-7] Kimmoun, Antoine; Novy, Emmanuel; Auchet, Thomas; Ducrocq, Nicolas; Levy, Bruno (2015). "Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside". Critical Care. 19 (1). doi:10.1186/s13054-015-0896-7. ISSN 1364-8535.

[KrautIngelfinger2014-8] Kraut, Jeffrey A.; Ingelfinger, Julie R.; Madias, Nicolaos E. (2014). "Lactic Acidosis". New England Journal of Medicine. 371 (24): 2309–2319. doi:10.1056/NEJMra1309483. ISSN 0028-4793.

[BrownMelamed2018-9] Brown, Denver; Melamed, Michal L. (2018). "New Frontiers in Treating Uremic Metabolic Acidosis". Clinical Journal of the American Society of Nephrology. 13 (1): 4–5. doi:10.2215/CJN.11771017. ISSN 1555-9041.

[KrautMadias2016-10] Kraut, Jeffrey A.; Madias, Nicolaos E. (2016). "Metabolic Acidosis of CKD: An Update". American Journal of Kidney Diseases. 67 (2): 307–317. doi:10.1053/j.ajkd.2015.08.028. ISSN 0272-6386.

[Gil-PeñaMejía2014-11] Gil-Peña, Helena; Mejía, Natalia; Santos, Fernando (2014). "Renal Tubular Acidosis". The Journal of Pediatrics. 164 (4): 691–698.e1. doi:10.1016/j.jpeds.2013.10.085. ISSN 0022-3476.

[Hemstreet2004-12] Hemstreet, Brian A (2004). "Antimicrobial-Associated Renal Tubular Acidosis". Annals of Pharmacotherapy. 38 (6): 1031–1038. doi:10.1345/aph.1D573. ISSN 1060-0280.

[ParkChoi2015-13] Park, Jin Joo; Choi, Dong-Ju; Yoon, Chang-Hwan; Oh, Il-Young; Lee, Ju Hyun; Ahn, Soyeon; Yoo, Byung-Su; Kang, Seok-Min; Kim, Jae-Joong; Baek, Sang-Hong; Cho, Myeong-Chan; Jeon, Eun-Seok; Chae, Shung Chull; Ryu, Kyu-Hyung; Oh, Byung-Hee (2015). "The prognostic value of arterial blood gas analysis in high-risk acute heart failure patients: an analysis of the Korean Heart Failure (KorHF) registry". European Journal of Heart Failure. 17 (6): 601–611. doi:10.1002/ejhf.276. ISSN 1388-9842.

[MannBajulaiye2014-14] Mann, Sarah; Bajulaiye, Akinyemi; Sturgeon, Kathleen; Sabri, Abdelkarim; Muthukumaran, Geetha; Libonati, Joseph R. (2014). "Effects of acute angiotensin II on ischemia reperfusion injury following myocardial infarction". Journal of the Renin-Angiotensin-Aldosterone System. 16 (1): 13–22. doi:10.1177/1470320314554963. ISSN 1470-3203.

[GuerrantVan_Gilder2001-15] Guerrant, R. L.; Van Gilder, T.; Steiner, T. S.; Thielman, N. M.; Slutsker, L.; Tauxe, R. V.; Hennessy, T.; Griffin, P. M.; DuPont, H.; Bradley Sack, R.; Tarr, P.; Neill, M.; Nachamkin, I.; Reller, L. B.; Osterholm, M. T.; Bennish, M. L.; Pickering, L. K. (2001). "Practice Guidelines for the Management of Infectious Diarrhea". Clinical Infectious Diseases. 32 (3): 331–351. doi:10.1086/318514. ISSN 1058-4838.

[ErlingssonHerard2009-16] Erlingsson, Styrbjörn; Herard, Sebastian; Dahlqvist Leinhard, Olof; Lindström, Torbjörb; Länne, Toste; Borga, Magnus; Nystrom, Fredrik H. (2009). "Men develop more intraabdominal obesity and signs of the metabolic syndrome after hyperalimentation than women". Metabolism. 58 (7): 995–1001. doi:10.1016/j.metabol.2009.02.028. ISSN 0026-0495.

[LangeBojunga2009-17] Lange, Christian M.; Bojunga, Jörg; Hofmann, Wolf Peter; Wunder, Katrin; Mihm, Ulrike; Zeuzem, Stefan; Sarrazin, Christoph (2009). "Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function". Hepatology. 50 (6): 2001–2006. doi:10.1002/hep.23346. ISSN 0270-9139.

[BilezikianPotts2002-18] Bilezikian, John P.; Potts, John T.; Fuleihan, Ghada El-Hajj; Kleerekoper, Michael; Neer, Robert; Peacock, Munro; Rastad, Jonas; Silverberg, Shonni J.; Udelsman, Robert; Wells, Samuel A. (2002). "Summary Statement from a Workshop on Asymptomatic Primary Hyperparathyroidism: A Perspective for the 21st Century". The Journal of Clinical Endocrinology & Metabolism. 87 (12): 5353–5361. doi:10.1210/jc.2002-021370. ISSN 0021-972X.

[TenNew2001-19] Ten, Svetlana; New, Maria; Maclaren, Noel (2001). "Addison's Disease 2001". The Journal of Clinical Endocrinology & Metabolism. 86 (7): 2909–2922. doi:10.1210/jcem.86.7.7636. ISSN 0021-972X.

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Renal tubular acidosis differential diagnosis

Overview

Differentiating Renal tubular acidosis from other diseases

References

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