Acidose métabolique “rénale” Colloque réveil Dr Vincent Bourquin - service de! néphrologie - http://nephroblog.org L’acidose métabolique de Quelques rappels l’insuffisance rénale est… L’acidose métabolique de l’insuffisance rénale est… à trou anionique… normal Anions = Cations Acidose métabolique trou anionique augmenté Acidose métabolique hyperchlorémique Principales causes d’acidose métabolique hyperchlorémique 1. Perte de bicarbonate Perte intestinale (diarrhées et autres causes) Remplacement de la vessie par un conduit iléal Médicaments (inhibiteur de l’anhydrase carbonique) Acidose tubulaire rénale proximale (type 2) 2. Diminution de l’excrétion rénale d’acides non volatils Acidose tubulaire rénale distale (classique ou de type 1) Acidose tubulaire rénale de type 4 Insuffisance rénale chronique (tardivement on retrouve une augmentation du TA) Nutrition parentérale Source: Robitaille, Le Médecin du Québec 2007 Au premier stade de l’insuffisance rénale, l’atteinte tubulaire conduit à une acidose métabolique hyperchlorémique Aux stades plus avancées, la rétention des anions organiques apparaît, ce qui conduit à une augmentation du trou anionique… Metabolic acidosis is a common complication of advanced CKD present in 30-50% of individuals with eGFR < 30 ml/min/ 2 1.73 m Source: Chen et coll. Am J Kidney Dis 2013 Low serum bicarbonate levels has been associated with increased mortality in patients with moderate and advanced CKD, as well as patients receiving both peritoneal dialysis and hemodialysis Source: Chen et coll. Am J Kidney Dis 2013 KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease 3.4.1: We suggest that in people with CKD and serum bicarbonate concentration < 22 mmol/l treatment with oral bicarbonate supplementation be given to maintain serum bicarbonate within the normal rage, unless contrindicated. (2B) Source: Kidney International Supplements (2013) 3, 5-14 Selected Adverse Effects of Chronic Metabolic Acidosis in CKD and Evidence for Alkali Therapy Adverse effect Evidence for Alkali Therapy Reduces calcium loss in non-dialysis dependent CKD; has benefit in children Enhance bone resorption and Bone disease with RTA, posmenopausal women with impairs bone formation normal kidney function, and dialysis patients Decrease albumin synthesis, Decrease protein degradation and may Protein metabolism increase muscle proteolysis, and increase albumin concentration; the cause negative nitrogen balance data are conflicting in dialysis patients May increase muscle mass and improve Muscle mass May contribue to muscle wasting function Could contribue to the May slow the progression to kidney Kidney function progression of CKD failure and development of ESRD Source: Chen et coll. Am J Kidney Dis 2013 Metabolic acidosis also contribute to the progression of CKD by promoting tubulointerstitial injury through ammoniainduced complement activation and endothelia and aldosterone activation. Source: Chen et coll. Am J Kidney Dis 2013 Metabolic acidosis also contribute to the progression of CKD by promoting tubulointerstitial injury through ammoniaQuelques études… induced complement activation and endothelia and aldosterone activation. Source: Chen et coll. Am J Kidney Dis 2013 Open-label, randomized, prospective, parallel group study with 134 patients with CKD stage 4 and serum bicarbonate levels of 16-20 mmol/l assigned to oral sodium bicarbonate treatment to maintain bicarbonate levels ≥ 23 mmol/l or to standard of care. e d u t E Source: Brito-Ashurst et coll. J Am Soc Nephrol 2009 e d u t Bicarbonate supplementation slowed the rate of GFR loss and reduced the progression to end-stage renal disease requiring dialysis E Source: Brito-Ashurst et coll. J Am Soc Nephrol 2009 e d u t Similar findings in patients with hypertensive nephropathy with serum total carbon dioxide levels < 22 mmol/l. Thirty patients prescribed sodium citrate were compared with 29 controls who were unable or unwilling to take the medications. E Source: Phisitkul et coll. Kidney Int 2010 e d u t A 5-year randomized, placebo-controlled, blinded study compare sodium bicarbonate treatment with placebo or equimolar sodium chloride (40 vs 40). The rate of GFR decline was slower in patients treated with sodium bicarbonate E Source: Mahajan et coll. Kidney Int 2010 Quel traitement ? Eaux alcalines Eaux alcalines um Nephr ot i de calc rans e acétat de sodium vela Ren Bicarbonate carbona te de ca lcium merci de votre attention Dr Vincent Bourquin - service de néphrologie - http://nephroblog.org