Renal tubular acidosis differential diagnosis

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

Overview

Renal tubular acidosis must be differentiated form other diseases as most of them have a similar presentation of acidosis on ABG, dehydration (nausea and vomiting) and specific history pertaining to underlying etiology.

Differentiating Renal tubular acidosis from other diseases

Renal tubular acidosis must be differentiated form other diseases as most of them have a similar presentation of acidosis on ABG, dehydration (nausea and vomiting) and specific history pertaining to underlying etiology.

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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