Generally speaking, metabolic alkalosis is a neglected and poorly understood beast. Perhaps there is an impression that it is somehow less dangerous and thus less interesting than metabolic acidosis. The acid-base enthusiast must become familiar with this process.

Exogenous strong cation excess

Sodium bicarbonate or citrate administration

β-lactam associated metabolic alkalosis

Exotic buffer substances, eg THAM

Milk-alkali syndrome and hypercalcemia in general

Primary derangement of homeostatic mechanisms

Failure of bicarbonate excretion in end-stage renal failure

Hypoalbuminaemia

Enteric chloride depletion

Dietary chloride restriction

Gastric loss of chloride ions

Chloride loss due to villous adenoma

Renal chloride depletion

Diuretic-induced metabolic alkalosis

Post-hypercapneic state

Bartter's syndrome and Gitelman's syndrome

Pseudo-Bartter's syndrome of cystic fibrosis

Hypokalemia

Hypomagnesaemia

Mineralocorticoid excess

Renin-secreting adenoma

Renal artery stenosis and malignant hypertension

Primary hyperaldosteronism

Licorice overindulgeance

Corticosteroids and fludrocortisone

Cushing syndrome

Causes of congential hyperadrenalism

Liddle syndrome

Again, I reproduce a table to list the various causes of metabolic alkalosis according to the findings of one's clinical examination history and biochemistry.

Causes of Metabolic Alkalosis; Organised by Diagnostic Features
Classification Causes and pathophysiology Literature reference

The diagnostic pathway can therefore be reduced into a flowchart:

The approach to metabolic alkalosis

Background history

  • History of congential adrenal hypoplasia
  • History of cystic fibrosis
  • History of CCF (suggesting chronic exposure to diuretics)
  • History of uncontrolled hypertension (malignant hypertension or renal artery stenosis)

Recent history

  • Recent antacic consumption
  • Recent use of calcium supplements
  • β-lactam antibiotic use
  • Massive abuse of licorice
  • History of diarrhoea (villous adenoma) or vomiting (chloride loss)
  • History of recent hypercapneic respiratory failure

Examination

  • Clinically, findings consistent with severe hypertension (eg. retinal changes)
  • Renal artery stenosis bruit
  • Peripheral oedema (suggesting chronic exposure to diuretics)

Biochemistry

  • Serum potassium
  • Serum magnesium
  • Urinary chloride
  • Serum renin levels
  • Serum aldosterone levels

References

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Zietse, Robert, Roeland Zoutendijk, and E. J. Hoorn. "Fluid, electrolyte and acid–base disorders associated with antibiotic therapy." Nature Reviews Nephrology 5.4 (2009): 193-202.

Zaki, Syed Ahmed, and Vijay Lad. "Piperacillin-tazobactam-induced hypokalemia and metabolic alkalosis." Indian journal of pharmacology 43.5 (2011): 609.

Kennedy, J. D., et al. "Pseudo-Bartter's syndrome in cystic fibrosis." Archives of disease in childhood 65.7 (1990): 786-787.

Mersin, S. S., et al. "Urinary chloride excretion distinguishes between renal and extrarenal metabolic alkalosis." European journal of pediatrics 154.12 (1995): 979-982.

Eiam-Ong, Somchai, Neil A. Kurtzman, and Sandra Sabatini. "Effect of furosemide-induced hypokalemic metabolic alkalosis on renal transport enzymes." Kidney Int 43 (1993): 1015-1020.

Luke, Robert G., and John H. Galla. "It is chloride depletion alkalosis, not contraction alkalosis." Journal of the American Society of Nephrology 23.2 (2012): 204-207.

Fujita, Kazushige. "(2) Clinical Study on Elevation of pH (Alkalemia) in Chronic Respiratory Failure, Especially Associated with Chronic Hypercapnia."Japanese Journal of Medicine 15.2 (1976): 154-155.

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STARR, ALBERT, STERLING MUELLER, and JOHN R. McKITTRICK. "Villous adenoma of the colon associated with severe hypopotassemia." AMA archives of surgery 73.6 (1956): 995-998.

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Baruch, Dominique, et al. "Diagnosis and treatment of renin-secreting tumors. Report of three cases." Hypertension 6.5 (1984): 760-766.

Laragh, John H., et al. "Aldosterone secretion and primary and malignant hypertension." Journal of Clinical Investigation 39.7 (1960): 1091.

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Schambelan, M., P. E. Slaton Jr, and E. G. Biglieri. "Mineralocorticoid production in hyperadrenocorticism: Role in pathogenesis of hypokalemic alkalosis." The American journal of medicine 51.3 (1971): 299-303.

GLYNN, RUSSELL D., et al. "Effects of glucocorticoid steroids on renal and systemic acid-base metabolism." (1980).

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