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Metabolic Acidosis: Causes, Symptoms and Treatment

Metabolic acidosis is a condition in which the blood becomes too acidic due to a disturbance in the body's acid-base balance. It requires prompt medical evaluation and treatment.

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Things worth knowing about "Metabolic Acidosis"

Metabolic acidosis is a condition in which the blood becomes too acidic due to a disturbance in the body's acid-base balance. It requires prompt medical evaluation and treatment.

What is Metabolic Acidosis?

Metabolic acidosis is a metabolic disorder in which the pH of the blood falls below the normal range of 7.35 to 7.45, indicating that the blood has become too acidic. This occurs either because the body produces too much acid, loses too much bicarbonate (HCO₃¯) — the blood's key buffering base — or because the kidneys are unable to remove sufficient acid. Maintaining a proper acid-base balance is critical for organ function, and significant deviations can be life-threatening.

Causes

Metabolic acidosis can result from a wide range of underlying conditions. Common causes include:

Diabetic ketoacidosis (DKA): A serious complication of diabetes mellitus in which excess ketone bodies lower blood pH.
Renal failure: Damaged kidneys cannot adequately excrete acids from the body.
Lactic acidosis: Excess lactic acid accumulates due to conditions such as shock, oxygen deprivation, or liver failure.
Poisoning: Substances such as methanol, ethylene glycol, or salicylates can cause severe acidosis.
Severe diarrhea: Significant loss of bicarbonate through the gastrointestinal tract lowers blood pH.
Renal tubular acidosis: A dysfunction of kidney tubules impairs acid secretion and bicarbonate reabsorption.

Symptoms

The symptoms of metabolic acidosis depend on its severity and the speed of onset. Common signs and symptoms include:

Rapid, deep breathing (Kussmaul respiration), a compensatory mechanism to expel CO₂
Fatigue and generalized weakness
Nausea, vomiting, and abdominal pain
Confusion, drowsiness, or loss of consciousness in severe cases
Cardiac arrhythmias caused by electrolyte imbalances
Low blood pressure (hypotension)

Diagnosis

The diagnosis of metabolic acidosis is primarily established through an arterial blood gas analysis (ABG), which measures blood pH, carbon dioxide partial pressure (pCO₂), and bicarbonate levels. Typical findings include:

Blood pH below 7.35
Serum bicarbonate below 22 mmol/l
Compensatory decrease in pCO₂ due to hyperventilation

Additional laboratory tests — including electrolytes, kidney function markers, blood glucose, lactate, and ketones — are used to identify the underlying cause. Calculation of the anion gap is a key diagnostic tool for distinguishing between different types of metabolic acidosis.

Treatment

Treatment is directed at the underlying cause of the acidosis:

Diabetic ketoacidosis: Insulin administration, fluid replacement, and electrolyte correction
Renal failure: Dialysis in severe cases, oral or intravenous bicarbonate supplementation
Lactic acidosis: Treatment of the primary condition (e.g., circulatory shock), oxygen therapy
Poisoning: Antidotes, activated charcoal, and dialysis if indicated
Sodium bicarbonate infusion: In selected severe cases, intravenous sodium bicarbonate may be administered to raise blood pH.

Close monitoring of laboratory values and vital signs is essential throughout treatment to assess response and prevent complications.

References

Kasper, D.L. et al. (eds.): Harrison's Principles of Internal Medicine, 21st edition, McGraw-Hill Education, 2022.
Emmett, M. & Narins, R.G.: Clinical use of the anion gap. Medicine (Baltimore), 1977; 56(1):38-54. PubMed PMID: 834782.
Kraut, J.A. & Madias, N.E.: Metabolic acidosis: pathophysiology, diagnosis and management. Nature Reviews Nephrology, 2010; 6(5):274-285. doi:10.1038/nrneph.2010.33.

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