Acid-base balance
The normal pH of the blood is maintained in the narrow range of 7.35–7.45, i.e. slightly
alkaline. The pH of intracellular fluid is rather variable. Thus, for erythrocytes the pH is 7.2,
while for skeletal muscle, it may be as low as 6.0. Maintenance of blood pH is an important
homeostatic mechanism of the body. In normal circumstances, the regulation is so effective
that the blood pH varies very little. Changes in blood pH will alter the intracellular pH which,
in turn, influence the metabolism e.g. distortion in protein
Production of acids by the body
The metabolism of the body is accompanied by an overall production of acids. These include
the volatile acids like carbonic acid (most predominent, about 20,000 mEq/day) or
nonvolatile acids (about 80 mEq/day) such as lactic acid, sulfuric acid, phosphoric acid etc.
Carbonic acid is formed from the metabolic product CO2 ; lactic acid is produced in
anaerobic metabolism; sulfuric acid is generated from proteins (sulfur containing amino
acids); phosphoric acid is derived from organic phosphates (e.g. phospholipids). All these
acids add up H+ ions to the blood. A diet rich in animal proteins results in more acid
production by the body that ultimately leads to the excretion of urine which is profoundly
acidic.
Production of bases by the body
The formation of basic compounds in the body, in the normal circumstances, is negligible.
Some amount of bicarbonate is generated from the organic acids such as lactate and citrate. A
vegetarian diet has a tendency for a net production of bases. This is due to the fact that
vegetarian diet produces salts of organic acids such as sodium lactate which can utilize H+
ions produced in the body. For this reason, a vegetarian diet has an alkalizing effect on the
body. This is reflected by the excretion of neutral or slightly alkaline urine by these subjects.
structure, enzyme activity etc. It is estimated that the blood pH compatible to life is 6.8–7.8.
Maintenance of blood pH
The body has developed three lines of defense to regulate the body's acid-base balance and
maintain the blood pH (around 7.4).
I Blood buffers
II Respiratory mechanism
III Renal mechanism.
Blood buffers
A buffer may be defined as a solution of a weak acid (HA) and its salt (BA) with a strong
base. The buffer resists the change in pH by the addition of acid or alkali and the buffering
capacity is dependent on the absolute concentration of salt and acid. It should be borne in
mind that the buffer cannot remove H+ ions from the body. It temporarily acts as a shock
absorbent to reduce the free H+ ions. The H + ions have to be ultimately eliminated by the
renal mechanism.
The blood contains 3 buffer systems.
1. Bicarbonate buffer
2. Phosphate buffer
3. Protein buffer.
Bicarbonate buffer system: Sodium bicarbonate and carbonic acid (NaHCO3 – H2CO3 ) is
the most predominant buffer system of the extracellular fluid, particularly the plasma.
Carbonic acid dissociates into hydrogen and bicarbonate ions.
It is evident from this equation that the pH is dependent on ratio of the concentration of the
base to acid (and H2CO3 in equation 4).
Blood pH and the ratio of to H2CO3 The plasma bicarbonate concentration is around 24
mmol/l (range 22– 26 mmol/l). Carbonic acid is a solution of CO2 in water.
Its concentration is given by the product of p CO 2 (arterial partial pressure of CO 2 = 40 mm
Hg) and the solubility constant of CO2 (0.03).
Thus H2CO3 = 40 × 0.03 = 1.2 mmol/l.
The Henderson-Hasselbalch equation for bicarbonate buffer is
It is evident that at a blood pH 7.4, the ratio of bicarbonate to carbonic acid is 20:1. Thus, the
bicarbonate concentration is much higher (20 times) than carbonic acid in the blood. This is
referred to as alkali reserve and is responsible for the effective buffering of H + ions, generated
in the body. In normal circumstances, the concentration of bicarbonate and carbonic acid
determines the pH of blood. Further, the bicarbonate buffer system serves as an index to
understand the disturbances in the acid-base balance of the body.
Phosphate buffer system: Sodium dihydrogen phosphate and disodium hydrogenphosphate
(NaH2PO4 - Na2HPO4) constitute the phosphate buffer. It is mostly an intracellular buffer
and is of less importance in plasma due to its low concentration. With a pK of 6.8 (close to
blood pH 7.4), the phosphate buffer would have been more effective, had it been present in
high concentration. It is estimated that the ratio of base to acid for phosphate buffer is 4
compared to 20 for bicarbonate buffer.
Protein buffer system : The plasma proteins and hemoglobin together constitute the protein
buffer system of the blood. The buffering capacity of proteins is dependent on the pK of
ionizable groups of amino acids. The imidazole group of histidine (pK = 6.7) is the most
effective contributor of protein -buffers. The plasma proteins account for about 2% of the
total buffering capacity of the plasma. Hemoglobin of RBC is also an important buffer. It
mainly buffers the fixed acids, besides being involved in the transport of gases (O2 and
CO2).
II. Respiratory mechanism for pH regulation
Respiratory system provides a rapid mechanism for the maintenance of acid-base balance.
This is achieved by regulating the concentration of carbonic acid (H 2CO3) in the blood i.e. the
denominator in the bicarbonate buffer system. The large volumes of CO 2 produced by the
cellular metabolic activity endanger the acid-base equilibrium of the body. But in normal
circumstances, all of this CO2 is eliminated from the body in the expired air via the lungs, as
summarized below
The rate of respiration (or the rate of removal of CO 2 ) is controlled by a respiratory centre,
located in the medulla of the brain. This centre is highly sensitive to changes in the pH of
blood. Any decrease in blood pH causes hyperventilation to blow off CO 2, thereby reducing
the H2CO3 concentration. Simultaneously, the H+ ions are eliminated as H2O. Respiratory
control of blood pH is rapid but only a short term regulatory process, since hyperventilation
cannot proceed for long.
Hemoglobin as a buffer Hemoglobin of erythrocytes is also important in the respiratory
regulation of pH. At the tissue level, hemoglobin binds to H + ions and helps to transport CO2
as with a minimum change in pH (referred to as isohydric transport). In the lungs, as
hemoglobin combines with O2 , H+ ions are removed which combine with to form H 2CO3 .
The latter dissociates to release CO2 to be exhaled.
Generation of by RBC
Due to lack of aerobic metabolic pathways, RBC produce very little CO 2 . The plasma CO2
diffuses into the RBC along the concentration gradient where it combines with water to form
H2CO3 . This reaction is catalysed by carbonic anhydrase (also called carbonate
dehydratase). In the RBC, H2CO3 dissociates to produce H+ and HCO 3 . The H+ ions are
trapped and buffered by hemoglobin. As the concentration of increases in the RBC, it diffuses
into plasma along with the concentration gradient, in exchange for Cl − ions, to maintain
electrical neutrality. This phenomenon, referred to as chloride shift, helps to generate HCO 3
Renal mechanism for pH regulation
The role of kidneys in the maintenance of acid-base balance of the body (blood pH) is highly
significant. The renal mechanism tries to provide a permanent solution to the acid-base
disturbances. This is in contrast to the temporary buffering system and a short term
respiratory mechanism, described above. The kidneys regulate the blood pH by maintaining
the alkali reserve, besides excreting or reabsorbing the acidic or basic substances, as the
situation demands.
Urine pH normally lower than blood pH. The pH of urine is normally acidic (~6.0). This
clearly indicates that the kidneys have contributed to the acidification of urine, when it is
formed from the blood plasma (pH 7.4). In other words, the H+ ions generated in the body in
the normal circumstances, are eliminated by acidified urine. Hence the pH of urine is
normally acidic (~6.0), while that of blood is alkaline (7.4). Urine pH, however, is variable
and may range between 4.5–9.5, depending on the concentration of H+ ions.
Carbonic anhydrase and renal regulation of pH
The enzyme carbonic anhydrase (inhibited by acetazolamide) is of central importance in the
renal regulation of pH which occurs by the following mechanisms.
1. Excretion of H+ ions
2. Reabsorption of bicarbonate
3. Excretion of titratable acid
4. Excretion of ammonium ions.
Carbon dioxide—the central molecule of pH regulation
CO2 is of central importance in the acid-base balance of the body. It has the ability to
combine with H2O to from H2CO3 which can dissociate to HCO3 and H+ . A summary of
the interaction between the lungs, erythrocytes and kidneys in handling CO2 to maintain pH
of the blood is depicted below. The CO2 generated by aerobic metabolism may be exhaled
via lungs, or converted to HCO3 by erythrocytes and kidneys to add up to the alkali reserve
of the body.
Buffers of intracellular fluids
The regulation of pH within the cells is as important as that discussed above for the
extracellular fluid. The H+ ions generated in the cells are exchanged for Na + and K+ ions.
This is particularly observed in skeletal muscle which reduces the potential danger of H+
accumulation in the cells.
Disorders of acid-base balance
The body has developed an efficient system for the maintenance of acid-base equilibrium
with a result that the pH of blood is almost constant (7.4). The blood pH compatible to life is
6.8–7.8, beyond which life cannot exist. For a better understanding of the disorders of acid-
base balance, the Henderson-Hasselbalch equation must be frequently consulted.
It is evident from the above equation that the blood pH (H+ ion concentration) is dependent
on the relative concentration (ratio) of bicarbonate (HCO3 ) and carbonic acid (H2CO3 ). The
acid-base disorders are mainly classified as
1. Acidosis—a decline in blood pH
(a) Metabolic acidosis—due to a decrease in bicarbonate. The primary defect in metabolic
acidosis is a reduction in bicarbonate concentration which leads to a fall in blood pH. The
bicarbonate concentration may be decreased due to its utilization in buffering H+ ions, loss in
urine or gastrointestinal tract or failure to be regenerated. Metabolic acidosis is commonly
seen in severe uncontrolled diabetes mellitus which is associated with excessive production
of acetoacetic acid and βhydroxybutyric acid (both are organic acids). The acute metabolic
acidosis is usually compensated by hyperventilation of lungs. This leads to an increased
elimination of CO2 from the body (hence H2CO3↓). but respiratory compensation is only
short-lived. Renal compensation sets in within 3–4 days and the H+ ions are excreted as NH4
ions
(b) Respiratory acidosis—due to an increase in carbonic acid. The primary defect in
respiratory acidosis is due to a retention of CO2 (H2CO3↑). There may be several causes for
respiratory acidosis which include depression of the respiratory centre (overdose of drugs),
pulmonary disorders (bronchopneumonia) and breathing air with high content of CO2 . The
renal mechanism comes for the rescue to compensate respiratory acidosis. More is generated
and retained by the kidneys which adds up to the alkali reserve of the body. The excretion of
titratable acidity and is elevated in urine.
2. Alkalosis—a rise in blood pH
(a) Metabolic alkalosis—due to increase in bicarbonate. The primary abnormality in
metabolic alkalosis is an increase in concentration. This may occur due to excessive vomiting
(resulting in loss of H+ ) or an excessive intake of sodium bicarbonate for therapeutic
purposes (e.g. control of gastric acidity). Cushing's syndrome (hypersecretion of aldosterone)
causes increased retention of Na + and loss of K+ from the body. Metabolic alkalosis is
commonly associated with low K+ concentration (hypokalemia).
The respiratory mechanism initiates the compensation by hypoventilation to retain CO2
(hence H2CO3↑). This is slowly taken over by renal mechanism which excretes more and
retains H+ .
(b) Respiratory alkalosis—due decrease in carbonic acid. The primary abnormality in
respiratory alkalosis is a decrease in H2CO3 concentration. This may occur due to prolonged
hyperventilation resulting in increased exhalation of CO2 by the lungs. Hyperventilation is
observed in conditions such as hysteria, hypoxia, raised intracranial pressure, excessive
artificial ventilation and the action of certain drugs (salicylate) that stimulate respiratory
centre. The renal mechanism tries to compensate by increasing the urinary excretion of .
The four acid-base disorders referred above are primarily due to alterations in either
bicarbonate or carbonic acid. It may be observed that the metabolic acid base balance
disorders are caused by a direct alteration in bicarbonate concentration while the respiratory
disturbances are due to a change in carbonic acid level (i.e. CO 2 ). This type of classification
is more theoretical. In the actual clinical situations, mixed type of disorders are common. The
terms acidemia and alkalemia, respectively, refer to an increase or a decrease in [H+] ion
concentration in blood.
Clinical causes of acid-base disorders
Metabolic acidosis could occur due to diabetes mellitus (ketoacidosis), lactic acidosis, renal
failure etc. Respiratory acidosis is common in severe asthma and cardiac arrest. Vomiting and
hypokalemia may result in metabolic alkalosis while hyperventilation and severe anemia may
lead to respiratory alkalosis.
Compensation of acid-base disorders
To counter the acid-base disturbances, the body gears up its homeostatic mechanism and
makes every attempt to restore the pH to normal level (7.4). This is referred to as
compensation which may be partial or full. Sometimes the acidbase disorders may remain
uncompensated.
For the acute metabolic disorders (due to changes in HCO3 ), respiratory compensation sets
in and regulates the H2CO3 (i.e. CO2 ) by hyper-or hypoventilation. As regards acute
respiratory disorders (due to changes in H2CO3 ), the renal compensation occurs to maintain
the HCO3 level, by increasing or decreasing its excretion.
Anion gap
For a better understanding of acid-base disorders, adequate knowledge of anion gap is
essential. The total concentration of cations and anions (expressed as mEq/l) is equal in the
body fluids. This is required to maintain electrical neutrality. The commonly measured
electrolytes in the plasma are Na + , K+ , Cl – and HCO3 . Na + and K+ together constitute
about 95% of the plasma cations. Cl − and HCO3 are the major anions, contributing to about
80% of the plasma anions. The remaining 20% of plasma anions (not normally measured in
the laboratory) include proteins, phosphate, sulfate, urate and organic acids. Anion gap is
defined as the difference between the total concentration of measured cations (Na + and K+ )
and that of measured anion (Cl − and HCO3). The anion gap (A − ) in fact represents the
unmeasured anions in the plasma which may be calculated as follows, by substituting the
normal concentration of electrolytes (mEq/l).
The anion gap in a healthy individual is around 15 mEq/l (range 8–18 mEq/l). Acid-base
disorders are often associated with alterations in the anion gap.
Mixed acid-base disorders
Sometimes, the patient may have two or more acid-base disturbances occurring
simultaneously. In such instances, both and H2CO3 are altered. In general, if the biochemical
data (of blood gas analysis) cannot be explained by a specific acid-base disorder, it is
assumed that a mixed disturbance is occurring. Many a times, compensatory mechanisms
may lead to mixed acid-base disorders.
Blood gas measurement
The measurement of blood gas is an important investigation in the laboratory service. In
certain conditions associated with respiratory failure and/or acidbase disorders, blood gas
(CO2 and O2 ) measurement assumes significance. Based on the results obtained and the
severity of the condition, oxygen treatment or artificial ventilation is carried out. For blood
gas analysis, a sample of arterial blood collected from (most commonly) radial artery in the
forearm, or (less commonly) from the femoral artery in the leg is used. The biochemical
profile measured include pO2, pCO2 , and pH (H+ ion concentration). The concentration of
bicarbonate is calculated by using Henderson-Hasselbalch equation. In fact, the blood gas
analysers employed in the hospitals are designed to perform the various calculations
automatically and give the final results.
The reference ranges of blood gas analysis are given below