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GU Block 1 Flashcards

1
Q

Where are kidneys and ureters located withing the body?

What are the 3 external layers covering the kidney?

A

Retroperitoneal, T11-L3

Fascia Adipose Capsules

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2
Q

What are the 3 internal layers of the kidneys

What is the functional organ, tissue and unit of the GU/kidney?

A

Cortex Medulla Pelvis

Kidney, Parenchyma, Nephron

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3
Q

Where do vessels and nerve structures enter/leave the kidney?

What is the path of blood to and from the kidney

A

Hilum

Abdominal aorta
Renal artery
Afferent arterioles
Glomerulus
Efferent arterioles
Peritubular capillaries
Vasa recta
Renal vein
IVC
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4
Q

What part of the NS regulates filtration and urine formation?

What other process is innervated here?

A

Sympathetic: superior mesenteric, innervates arterioles

RAAS- dec BP
Renin secretion- inc BP

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5
Q

What does a nephron consist of?

Where do ACEIs/ARBS exert their effects?

A 
Renal corpuscle (glomerulus, Bowmans)
Renal tubules (PCT, LoH, DCT)

Afferent arteriole

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6
Q

What are the 8 major functions of the kidneys?

A 
Regulate blood ions, pH, volume
BP regulation
Maintain blood osmolarity
Produce hormones
Regulate blood glucose
Excrete wastes
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7
Q

Kidneys regulate blood levels of what 5 E+

Where is renin secreted from and leads to ? result?

A

Na K Ca Cl PO4

Juxtaglomerular cells
Inc BP

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8
Q

Kidneys maintain blood osmolarity at ?

What are the two hormones produced in the kidneys?

A

300/L

Calcitriol- active form of Vit D, regulates PO4/Ca
EPO- stim production of RBCs in marrow

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9
Q

Production of urine is the end result of what 3 processes?

Define Glomerular Filtrate

A

Glomerular filtration
Tubular reabsorption
Tubular secretion

Fluid entering capsular space

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10
Q

What are the 3 components of glomerular filtration membrane?

A

Fenestrations- allows proteins/excludes cells/platelets

Basal lamina- allows small/med proteins through

Slit membrane- located between pedicels, only allows very small proteins through

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11
Q

Define Filtration Fraction

How much blood flows through kidneys?

How much GFR flows through kidneys each day?

A

Ratio of fluid from blood that becomes glomerular filtrate- 20% of total fluid reaching kidney becomes capsular space

1-1.2L/min

140-180L/day

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12
Q

What is a normal net filtration pressure w/in kidneys?

What are the 3 pressures and the changes occurring during glomerular filtration

A

10mmHg

Glomerular hydrostatic- 55mmHg
Capsular hydrostatic- 15mmHg
Blood colloid- 30mmHG

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13
Q

Water makes up 95% of urine, how much Na and K is found normally?

What is the fluid capacity of the bladder?

A

Na- 1g/L
K- 0.75g/L

700-800mL

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14
Q

What are the 3 layers of the bladder?

A

Mucosa- transitional epitherlium

Muscularis- detrusor

Serosa- superior surface covering or,

Adventitia- covers post/inf surface and continuous w/ ureters

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15
Q

2/3 of body water is ? and remaining 1/3 is ?

Of the 1/3 part, how much is intravascular?

A

2/3: intracellular
1/3: extracellular

1/4

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16
Q

Define Osmolality

Define Osmolarity

A

Solution concentration expressed as total solute particles/kg

Solution concentration expressed as total milimoles/L

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17
Q

Fat’s water content is ? than muscle

This is why obese people’s ratio is ?

A

Lower than muscle

Lower ratio of total body water to body weight

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18
Q

Define Tonicity

A solution’s tonicity is related to its ?

A

Ability of extracellular solution to make water move in/out of cell via osmosis

Osmolarity, total concentration of all solutes in a solution

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19
Q

Define Hypotonic

Define Isotonic

Define Hypertonic

A

ECF w/ lower osmolarity than the ICF, net flow is into cell

Same osmolarity between ICF/ECF w/ no water movement

ECF w/ higher osmolarity than inside the cell, water moves out of cell

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20
Q

What is the gold standard for evaluating renal E+ excretion?

What is a better method?

A

24hr urine collection

Fractional excretion of an E+ from spot urine samples

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21
Q

What does a Low FEx indicate?

What does a High FEx indicate?

A

Renal absorption, high avidity/E+ retention

Renal wasting, low avidity/E+ excretion

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22
Q

What does an FEx below 1% mean?

What does an FEx above 2% mean?

A

Pre-renal Dz (low output HF)

Acute tubular necrosis

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23
Q

What is the natural physiologic response to a decrease in renal perfusion?

Why is the natural response of sodium wasting seen w/ high FEx

A

Inc Na reabsorption

Tubular necrosis causes loss of Na/hypervolemia

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24
Q

Physiologic solute concentration is normally between ?

Define Tonicity

A

285-295mmol/kg

Osmolytes that are impermeable to cell membranes

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25
# Define Ineffective Osmoles What is the major extracellular cation
Substances that easily permeate cell membranes and don't contribute to tonicity and don't cause shifts across compartments Na
26
# Define Osmolal gap What does the presence of this gap suggest?
Discrepancy between measured and estimated osmolality more than 10mmol/kg Presence of unmeasured osmoles- ethanol, methanol, ethylene glycol, mannitol, propylene glycol and isopropanol
27
Normally, how many mosmols need to be excreted each day? What is the max urine osmolality? What is the minimum urine output required for neural solute balance
60 1200mosmol/kg 500mL/day
28
Obligatory renal water loss is mandated by ? How is serum sodium calculated
Minimum solute excretion required to maintain a steady state Exchangeable Na + Exchangeable K/ Total body water
29
What is the primary stimulus for water ingestion? What mediates this stimulus
Thirst Inc effective osmolality Dec ECF volume
30
Osmoreceptors are stimulated by ? What is the average osmotic threshold for thirst?
Rise in tonicity 295 mosmol/kg
31
What is the major stimulus for ADH release Osmolality is primarily determined by ?
Hypertonicity Na concentrations
32
What are the 3 steps required for maintaining homeostasis and normal plasma Na
Filtration, delivery of water/E+ to diluting site of nephron Active reabsoprtion of Na/Cl w/out water in ascending LoH Maintenance of dilute urine due to CD impermeability if no ADH is present
33
Hypotonic fluids often contribute to hospitalized PTs acquiring ? Hyponatremia start at ? level and reflects ?
Hyponatremia- MC E+ abnormality in hospitalized PTs from too much IV fluid <135mEq Excess water relative to Na levels
34
# Define Isotonic Hyponatermia What two conditions can this occur in?
Pseudohyponatremia- lab error underestimating Na concentrations Hyperlipidemia Hyperproteinemia
35
Pseudohyponatremia does not occur if serum Na is measured by ? Hypertonic Hyponatremia is AKA and defined as ? What type of result does this cause?
Ion specific electrode in direct assay of undiluted serum specimen Translocational Hyponatremia- large amounts of substance can't cross membrane, added to ECF compartment Pulls intracellular water into ECF, dilutes sodium
36
What are two examples of Hypertonic hyponatremia etiologies What type of d/o is this?
Hyperglycemia Iatrogenic mannitol administration Water redistributing in response to change of tonicity
37
Most causes of hyponatremia are ? What are the 3 categories
Hypotonic Hypovolemic Hypo Hypo Euvolemic Hypo Hypo- STREP Hypervolemic Hypo Hypo
38
Hypovolemic Hypotonic Hyponatremia
Occurs d/t extra/renal volume loss w/ hypotonic replacement Total Na and water dec ADH release= retained water Osmolality sacrificed to preserve intravascular volume
39
What urine Na results indicate if volume loss is renal or extrarenal? SIADH
Renal: >20 mEq Extra: <10 mEq Hypo Hypo Hypo ADH released d/t hyperosmolality/dec arterial volume Inappropriate water retained= concentrated urine (+300mEq) w/ high Na (>20mEq)
40
What are 3 common causes of Hypo Hypo Hypo-SIADH Hypo Hypo Hypo- Hormonal abnormalities
CNS Pulm d/o and Malignancy Severe hypothyroid and glucocorticoid insufficiency; can NOT be differentiated from SIADH w/ urine/serum results
41
Hypo Hypo Hypo Psychogenic Polydipsia and Low Solute diet Hypo Hypo Hypo- Reset Osmostat
PT ingests normal solute diet but also 10-15L of water; kidney retain water, can't excrete pure water Appropriate ADH response to water deprivation/fluid challenges (pregnancy)
42
Hypo Hypo Hypo Exercise associated Why are sports drinks not actually that good?
Combo of excessive hypotonic intake w/ inappropriate ADH secretion (basic trainee forced hydration) Hypotonic compared to serum
43
Hypervolemic Hypotonic Hyponatremia
Cirrhosis, HF, Nephrotic syndrome, Adv KDz Cirr/HF- dec volume from dilation/dec output causes ADH secretion Dec osmolality in attempt to restore arterial volume
44
What are the Sxs of hyponatremia What causes more severe Sxs What labs would be considered?
Mainly neuro/brain edema Mild 130-135: gait fall Fx Sev <120: seizure herniation coma death Sudden/rapid E+ shifts Serum: E+ Cr Osmolality Urine: Na K Osmolality Thyroid/Adrenal function
45
What will be seen on lab results to Dx SIADH What will be seen on lab results in Pseudohypnatremia and how is it Tx
``` Normal thyroid/adrenal function Urine Na >20mEq Dec BUN <5-10mg Hypouricemia <4mg ADH levels not required ``` HyperTG, Hyperproteinemia No Tx req'd
46
How is Translocational Hyponatremia Tx How fast does chronic hypotonic hyponatremia need to be corrected? What can happen if Tx is too fast?
Tx hyperglycemia, d/c Mannitol 4-6mEq/L/24hrs No more than 6-8/24 Osmotic demyelination syndrome (central pontine myelitis)
47
If hyponatremia is Tx too quickly, what S/Sxs will be seen? What is the adverse outcome of Tx Translocational HypoNa too quickly?
Flaccid paralysis Dysarthria Dysphagia Rapid reduction of osmolality= cerebral edema
48
How is Hypovolemic HypoNa Tx How is Hypotonic Hpervol HypoNa Tx
Isotonic fluids to suppress hypovolume stimulus to release ADH Loop diuretics PTs w/ A/CKDz- dialysis
49
How is Psychogenic Hypo Euvo Hypo Tx How is Hypo Euvo Hypo 2* to SIADH Tx
Psych- Water restriction Low solute diet- water restriction, inc solute diet Fluid restriction D/c offender Furosemide/Demelocycline Sxs/resistant- vasopressin 2 antagonist (Tolvaptain)
50
Do these PTs stay in fluid restricted status when taking Tolvaptain? How are PTs w/ Sxs or severe hyponatremia Tx How are PTs w/ chronic hyponatremia Tx to avoid demyelination?
No fluid restrictions, can lead to excessive Na correction Admit Consult D/c Seizures= 100mL 3% saline across 10min for Sx relief 24hr correction 4-6mEq 100mL 3% at 0.5-5mL/kg/hr
51
When Tx HypoNa, what finding may signal excess ADH secretion has stopped and PT is at risk for over correction What class of med is added to Tx of HypoNa in PTs w/ CHF?
High hourly urine output Vasopressin 2
52
How are PTs w/ seizure/coma from HypoNa Tx
``` 100mL 3% over 10-15min Measure levels, stop at 5mEq Rpt, max of 300mL KLO w/ 0.9% NS Max increase of 8mEq in first 24hrs ```
53
Causes of Isotonic HypoNa Causes of Hyper Hypo
Hyperproteinemia Hyperlipidemia Hyperglycemia Mannitol Contrast
54
Causes of Hypo Hypo w/ <10 mEq Causes of Hypo Hypo w/ >20
GI Skin 3rd space Diuretic Nephropathies Mineralcorticoid deficiency CSWSyndrome
55
Causes of Hypo Euvolume Causes of HypoNa HyperVol
<100: Pysch, low solute diet >100: SIAD Hypothyroid Glucocorticoid deficiency Variable- reset osmostat HF Cirrhosis Nephrotic syndrome AKDz
56
When do PTs w/ HypoNa need to be referred? What are the two main defenses against hypernatremia? What is used to differentiate renal/non-renal water loss?
Severe Sxs Hypertonic V2 dialysi Severe liver/heart dz Inc thirst/water intake Urine osmolality
57
What is the defining criteria for HyperNa All PTs w/ hypernatremia have ? which usually stimulates ? responses
>145mEq Hyperosmolality- usually triggers ADH and thirst
58
What is a less common form of HyperNa that occurs in hospitalized PTs What type of HyperNa is usually mild and ASx
Hypervolemic HyperNa HyerpNa in Primary aldosteronism
59
What is a renal cause of HyperNa? What are two non-renal causes of HyperNa?
Diabetes insipidus GI loss Burns
60
S/Sxs of HyperNa
Lethargy Irritable Weak= early signs Hyperthermia Delirium Seizure/Coma in severe
61
Since all PTs w/ HyperNa are hyperosmolality too, what S/Sxs are seen at different osmolality ranges? HyperNa lab results showing urine osmolality is >400 can point to ? non/renal etiologies
320-330: somnolence, confusion 340-350: coma death Non-renal: low intake, hypotonic fluid loss Renal- glycosuria
62
HyperNa lab results showing urine osmolality <250 can be due to ? issues What are some common causes?
Diabetes insipidus- Central: dec ADH release Nephrogenic: ADH insensitivity Lithium Demecyocycline Obstruction relief Interstitial nephritis HyperCa/HypoK
63
What happens if HyperNa is Tx too quickly What is the fluid Tx of choice for hyperna w/ hypo volume
Cerebral edema Neuro impairment Isotonic to restore volume then hypotonic PO water is excellent
64
How is HyperNa w/ Euvolume Tx What caution needs to be taken when treating PTs w/ dec GFR?
Water ingestion IV 5% dextrose Adding diuretic may increase Na excretion, but impair renal concentration
65
How is HyperNa w/ Hypervolume Tx How is acute hyperNa Tx
5% dextrose to red hyperosmolality Loop diuretics to promote urination/lower Na Possible dialysis 5% dextrose if lost free water Continue therapy w/ 0.45%NS w/ dextrose
66
How is chronic HyperNa Tx In HyperNa, total body water is ? in men and ? in women
W/ goal to restore 140mEq Max Na correction- 10mEq/day PO water preferred if safe or, 5% dextrose IV M: 50% x kg F: 40% x kg
67
When do Pts w/ HyperNa need to be referred or admitted Equation for free water deficit
Refer: refractory/unexplained Admit: symptomatic TBW * Na-140/140 M- 50% W- 40%
68
What is used to distinguish renal from non-renal cause of K loss What is the MC cause of K
Transtubular K concentration gradient GI- infectious diarrhea
69
HypoK and acidosis suggests ? What two med classes need to be avoided to decrease risk of arrhythmias
Profound K depletion B 2 agonists and diuretics
70
HypoK increases chances of ? toxicity What needs to be considered in PTs w/ hypoK that is refractory to Tx
Digitalis HypoMg
71
Low k+ can lead to what 2 adverse events ? drug can cause substantial renal loss of K
Arrythmias Rhabdo Loop diuretics
72
S/Sxs of mild HypoK The presence of HTN may indicate there is excess of ?
Mild: Weak Fatigue Cramps Sev: flaccid paralysis hyporeflexia hypercapnia Aldosterone Mineralcorticiods
73
What are renal manifestations of hypoK If working up HypoK, what is seen on urine results?
Nephrogenic Di Interstitial nephritis Low: extra renal loss, V/D High: mineral corticoid excess
74
What does a Transtubular K Gradient TTKG >4 indicate? What will be seen on EKG?
K+ loss w/ inc distal K secretion Dec amplitude Broad T w/ U waves Premature V contractions Depressed ST segments
75
How is HypoK Tx
PO- safest/easiest for mild/mod IV 40mEq if severe/non-PO w/ constant EKG monitoring Avoid glucose fluids Check Mg if refractory
76
When is HypoK referred or admitted How can PTs develop acquired HyperK
R: unexplained refractory alternative Dx A: Sx and Severe- cardiac manifestations ACEI/ARB K+ sparing diuretics
77
What is the ratio of K+ inc to pH inc Persistent mild HyperK w/out presence of ACEI/ARB is usually due to ?
K inc 0.7/0.1pH inc Type 4 tubular acidosis
78
S/Sxs of HyperK What is the first step in Dx
Flaccid paralysis Weakness Ileus Repeat labs, especially if no meds are present
79
What are the indications to Tx HyperK urgently How is HyperK urgently Tx
Cardiac toxicity Muscle paralysis >6.5 Insulin BiCarb B-agonist Dialysis if A/CKDz
80
Name of medication used to Tx HyperK in PTs w/ CKD and already on drug that inhibits RAAS MOA of CaGluconate MOA of BiCarb, Insulin and Albuterol
Patiromer Antagonize cardiac conduction Distributes K into cells
81
Of the 4 meds used to Tx HyperK, do any remove K from body When are HyperK PTs referred/admitted
No, all shift K into cells Ca only one that DOESNT shift K to cells R: HyperK from renals Dz and reduced K excretion A: >5.5, any EKG changes or Concomitant
82
What can cause PTs to develop HypoCa MC cause of low total serum Ca is ? What is the most accurate method of measuring
Dec PTH VitD or Mg Hypoalbuminemia Ionized Ca concentration
83
True HypoCa indicated insufficient action of ? What is the MC cause of HypCa
PTH or Vit D Adv CKDz- dec Vit D3 production and Hyperphosphatemia catalyze
84
S/Sxs of HypoCa What EKG changes will be seen?
Cramps Spasms Convulsions Chvostek sign Trousseau sign QT prolongation predisposes ventricular arrhythmias
85
How does serum phosphate present during HypoCa What other E+ is commonly low in HypoCa
Inc in hyperparathyroidism/adv KDz Dec early CKDz or Vit D deficiency Mg
86
How is Sx/Sev HypoCa Tx How is ASx HypoCa Tx
10-15mg Ca/kg Monitor serum q4-6hrs PO Ca and Vit D/sterols Monitor urinary Ca excretion
87
When is HypoCa referred/admitted What are the MC causes of HyperCa
R: Complicated from hyperparathyroid, familial hypoCa or CKDz A: PTs w/ tetany, arrhythmia seizure or severe ASx/Mild: Hyperparathyroid Sev: Malignancy related HyperCa
88
What PE/lab finding may be seen indicating pending hypercalcemia HyperCa levels above ? usually indicate malignancy
Hypercalciuria >14mg
89
What is the MC cause of hyperCa in ambulatory PTs What type of HyperCa presentation suggest benign cases
Primary hyperparathyroidism Chronic Nephrolithiasis
90
What is the MC paraneoplastic endocrine syndrome What is this the MC cause of
Tumor producing PTH related proteins HyperCa in InPts
91
How/why do granulomatous Dzs cause HyperCa Define Milk-Alkali Syndrome
Sacroidosis/TB cause HyperCa via overproduction of active Vit D3 Ca ingestion to prevent osteoporosis causes AKI from renal constriction
92
Sxs usually appear when Ca levels pass ? What Sxs may be seen in mild cases? What is seen in severe cases
>12mg ASx, constipation N/V anorexia Weak Drowsy Coma Death
93
What are clinical findings seen w/ HyperCa
Ionized Ca >1.32 Hyperparathyroid- high serum Cl, low serum phosphate Mild Alkali syndrome- low Cl, high BiCarb- Hypocalciuric Hypercalcemia Malignancy- >14mg
94
How to differentiate Hyperthyroid or malignancy induced HyperCa How is HyperCa Tx
Hyperthyroid- inc PTH Malignancy- dec PTH, inc PTHrP Promote excretion- calciuresis Dec volume but normal Heart/kidney- 0.9% NS
95
What is the Tx of Choice for malignancy inducer HyperCa Kidney is most important regulator of serum ?
Bisphosphonates, take 72hrs Calcitonin as bridge Phosphate levels
96
If need to measure serum phosphate is needed, what does PT need to do What PT population is severe hypophosphatemia commonly seen in?
Fasting, phosphate decreases w/ food intake Alcoholics
97
What will be seen on lab findings when investigating hypophosphatemia How is hypophosphatemia Tx
Urine excretion <100mg/day If PT has DKA- diet POR replacement preferred Chronic- PO repletion mixture of Na/K phosphate Severe Sx- infusions
98
S/Sxs of acute/severe hypophosphatemia S/Sxs of chronic/sev hypophosphatemia What are c/is to replacing phosphate to Tx hypophosphatemia
Rhabdo Encephalotphaty Parasthesis Fx Anorexia Pain Hypoparathyroid Advanced CKD Tissue damage/necrosis Hypercalcemia
99
What is the MC cause of hyperphosphatemia How can hyperphophatemia be Tx
Advanced CKD w/ dec urinary excretion Dec dietary intake Phosphate binders- Ca carbonate/acetate Dialysis if A/CKDz
100
If dec Mg levels are suspected, what is the first lab ordered? Low levels can manifest w/ ? Sxs Low Mg will impair the release of ? endocrine hormone?
Urine Neuro Sxs Arrhythmias PTH
101
What are etiologies of HypoMg Since HypoMg also suppresses PTH, what other issues will be seen?
Diuretics Diarrhea Alcoholism Aminoglycosides Amphotericin Organ resistance to PTH and dec Vit D3 levels= HypoCa that is refractory to Ca Tx methods
102
S/Sxs of HypoMg How is it Tx
HypoCa/HypoK Babinksi response Athetoid movement HTN/Tachy Chronic- Mg Oxide Sx- Mg sulfate
103
What are two potential exogenous sources of HyperMg What are the characteristic manifestations of HyperMg
Antacids Laxatives Weak, Dec DTRs, Confusion
104
What is seen on lab results for HyperMg What is seen on EKG
Inc MG If Pt has CKD- inc BUN, Cr, K, PO4 and Uric acid Low Ca Inc PR interval Broad QRS Peaked T waves d/t HyperK
105
How is HyperMg Tx In order to assess PTs acid-base status, what 3 things need to be measured?
IV Ca chloride Dialysis if severe CKDz Arterial pH, PCo2- blood gas analyzer Plasma BiCarb
106
Since arterial and venous blood gases won't be equivalent during cardiopulmonary arrest, where/what are the most accurate measurements? Acidotic is below ? w/ ? PCo2 and BiCarb measurements
Arterial pH and PCO2 <7.40 PCO2 <40 BiCarb >24
107
There can be mixed acid-base d/os but there will never be ? What are the 5 steps of determining acid-base d/os
Two primary respiratory d/os ``` Primary d/o, met/resp Presence of mixed d/o Calculate anion gap Calculate corrected BiCarb concentration Examine PT ```
108
What is the Anion Gap formula What are the two reasons for calculating anion gaps?
Gap= Na - (HCO3 + Cl) ID abnormal gap w/ normal E+ Gap >20 suggest primary metabolic regardless of pH/bicarb, abnormal anion gap is never compensatory response to respiratory d/o
109
A wide anion gap means there are ? located in the ? What 3 issues form the largest anion gaps?
Unaccounted ions in serum Lactic acidosis Ketacidosis Toxins
110
Metabolic acidosis w/ normal anion gap is caused by what 2 issues How can the cause be distinguished?
GI BiCarb loss or RTA Urine anion gap
111
What is the hallmark of metabolic acidosis What underlying issues can cause the interpretation of the anion gap to be more difficult
Dec BiCarb Hypalbumin ABX Reduction unmeasured anion/ Inc unmeasured cations
112
What effect does hypoalbuminemia have on an anion gap? What are the 4 principle causes of inc anion gap metabolic acidosis
2 mEq dec in gap occurs for every 1g decline of albumin Lactic acidosis Ketacidosis Ingested toxins Acute/chronic renal failure
113
What effect does uremia have on an anion gap? What type of gap does lactic acidosis create? ? types of PTs may present w/ Type B Lactic Acidosis
Inc gap Elevated gap, dec pH w/out other acid-base disturbances UnDx/poorly controlled DM Alcholics PTs in shock
114
What type of gap does DKA create What two pieces of info are used to monitor/track PT improvement during Tx
Hyperglycemia, acidosis and inc gap Clinical status pH
115
What are the 3 types of metabolic acidosis seen in alcoholic PTs What type of anion gap can develop from volume contraction/vomiting
Ketoacidosis Lactic acidosis Hyperchloremic acidosis from BiCarb loss in urine Metabolic alkalosis
116
What can cause respiratory alkalosis to develop/ What lab results are used to support a Dx of alcoholic ketoacidosis
Pain Alcohol withdrawal Liver dz Sepsis No DM Hx Normoglycemia after initial therapy
117
What type of poisoning can present w/ a normal anion gap How would Isopropanol poisoning show?
Toluene poisoning Inc osmolar gap, unaffected anion gap
118
# Define Uremic Acidosis What are two major causes of normal anion gap acidosis
GFR <30= kidney can't synthesize NH3 Reduced H+ and organic acid excretion inc anion gap metabolic acidosis GI BiCarb loss- N/V/D Renal tubular acidosis Use urine anion gap to differentiate

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