PHYSIOLOGY

Acidebase physiology Learning objectives

Mohamed Abdelmotieleb After reading this article, you should be able to understand:
C body mechanisms for maintaining a consistent pH
Andrew Martin
C how the Stewart approach works to acidebase regulation

Abstract
The traditional approach to acidebase physiology is based on the free Ca2þ within the sarcomere available to react with troponin
HendersoneHasselbalch equation which is derived from the CO2/ and reduces the number of actin-myosin interactions. This, in
HCO3- buffer system. It is becoming increasingly recognized that turn, leads to a reduction in the force of contraction of the muscle.
this is an incomplete analysis, as it focuses on only one of the six The body uses alterations in pH to its advantage, as demon-
reactions involving Hþ. It can lead to the incorrect assumption that strated by the function of the haemoglobineoxygen dissociation
CO2 and HCO3- are independently adjusted factors, that ultimately curve. Haemoglobin is constructed of four haem units (2⍺, 2b).
determine pH. In 1983, Peter Stewart, a Canadian physiologist, There is a degree of flexibility in how they are joined, and the
proposed that a fuller understanding of acidebase physiology required spatial arrangement alters the availability of the binding points
consideration of biological fluids as a complex dynamic system, with for oxygen. There are two conformations, a relaxed (R) high
the interactions of all the chemical species involved considered. He oxygen affinity form and a taut (T) low affinity form. An increase
showed that the true independent variables controlling the pH of any in [Hþ] causes protonation of the N-terminal amino group of the
given fluid compartment are the difference in the concentration of ⍺-subunit and the C-terminal histidine of the b-subunit, thereby
‘strong ions’; the total concentration of ‘weak acid’; and the PCO2. stabilizing the T form and reducing the oxygen affinity of
Importantly, Hþ and HCO3- are dependent variables and it is incorrect haemoglobin e the dissociation curve moves to the right. This is
to think of them as being specifically regulated to manipulate pH. This known as the ‘Bohr effect’.
review will discuss the importance of pH homeostasis and highlight
the implications of the Stewart approach in our understanding of
Balance between acidebase production and clearance
acidebase control mechanisms and disorders. In particular, the true
mechanisms by which the kidney regulates plasma pH will be The main problem faced by the human body homeostatic control
discussed, emphasizing key misconceptions that have been mechanisms, is the defence against a massive daily acid load.
propagated because of the traditional approach. The acid produced by the body can be thought of as either
volatile or non-volatile:
Keywords Acidebase physiology; acidosis; Stewart approach

Royal College of Anaesthetists CPD Skills Framework: scientific principles Volatile acid is mainly carbonic acid (H2CO3) which is produced
by the hydration of CO2:

CO2 þ H2O4H2CO3 4 Hþ þHCO3-

What is acidosis and what is its relevance?
Therefore, although CO2 is not itself an acid, as it does not
contain a hydrogen ion to donate, it can instead be thought of as
pH ¼ - log10[Hþ] representing a potential to create an equivalent amount of
carbonic acid. At rest (with a CO2 production of 200 ml/minute),
The normal blood pH is 7.35e7.45; this relates to a hydrogen ion the daily load of CO2 is at least 15,000 mmol/day.
concentration [Hþ] of 35e45 nmol/litre. An acidosis is defined as
a pH below 7.35. pH above 7.45 is an alkalosis. Although the [Hþ] Non-volatile acids contribute much less to daily acid production,
(in nmol/litre) has a concentration 1/1,000,000 of other common with a net production of 1e1.5 mmol/kg/day or 70e100 mmol of
ions (Naþ 135 mmol/litre, Cl- 105 mmol/litre), it gains a major Hþ per day in an adult.
significance as the chemical reactions of many biological The non-volatile acids are subclassified as organic acids
processes, enabled by enzymatic proteins, are highly dependent (lactate, free fatty acids and b-hydroxybutyrate) and inorganic
on pH. For example, during vigourous exercise, lactic acid acids (sulphuric, phosphoric acid). These are bases rather than
accumulates in skeletal muscle. This is a strong acid, with a pKa of acids, however, this terminology is commonplace because they
3.8, that rapidly dissociates to lactate and Hþ ions, leading to a have been formed by the liberation of an Hþ from their parent
reduction in the intracellular pH. This lowers the concentration of acid. The amounts are several orders of magnitude greater than
the normal body Hþ concentration and thus, robust defence
mechanisms are essential for conditions compatible with life.
Mohamed Abdelmotieleb MB ChB EDAIC FRCA Senior Locally These include:
Employed Doctor in Anaesthesia at Manchester Royal Infirmary, UK. (i) Neutralization via buffer systems (seconds to minutes)
Conflict of interest: none declared. (ii) Exhalation by the respiratory system (minutes to hours)
Andrew Martin MB ChB FICM FRCA MCRP Consultant in Intensive Care (iii) Clearance by the renal system (hours to days).
Medicine & Anaesthesia at Manchester Royal Infirmary, UK. Conflict To understand these mechanisms, it is first necessary to
of interest: none declared. understand the principles of buffer systems within the body.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:5 327 Ó 2024 Published by Elsevier Ltd.
 PHYSIOLOGY

Physicochemical buffering oxyhaemoglobin can combine with CO2. Hb- is less acidic than
OxyHb- and can combine with more Hþ (3.5 times greater af-
A buffer is a solution that resists changes in pH when an acid or
finity). This is known as the ‘Haldane effect’.
base is added to it. A buffer consists of an undissociated weak
acid (HA) and its conjugate base (A-) and can be represented by:
Alternative approach: the Stewart method
þ
HA 4 H þ A -
In 1983, physiologist Peter Stewart proposed an alternative
approach to acidebase regulation. He proposed that a full un-
A buffer typically consists of a solution that contains a weak acid derstanding of acidebase physiology requires consideration of
(HA) mixed with the salt of that acid (e.g. NaA). The principle is biological fluids as a complex dynamic system: one needs to
that the salt provides a reservoir of A- to replenish [A-], when A- consider all the chemical species involved and how they interact
is removed by reaction with Hþ. The body has a huge buffering chemically with each other.
capacity and as this process happens instantaneously, physico- He made the argument that the traditional approach only fo-
chemical buffering provides a powerful first defence against acid- cuses on one of six reactions that involves Hþ ions, and ignores
base disturbances. the other five:
The main buffer systems in the different fluid compartments  water: H2O 4 Hþþ OH-
of the body can be either intracellular or extracellular (Table 1):  ‘weak’ acids in water (mainly protein and inorganic
The main buffer system in the extracellular fluid is bicar- phosphate): HA 4 Hþ þ A
bonate/carbonic acid:  carbonate: CO32- þ Hþ 4 HCO3-
 bicarbonate: HCO3- þ Hþ 4 CO2 þ H2O
CO2 þ H2O 4 H2CO3 4 HþþHCO3-
 electrical neutrality equation:

Since the concentration of carbonic acid is very low compared to [SID] þ [Hþ] ¼ [HCO3-] þ [A-] þ [CO32- ] þ [OH-]
the other components, the acid moiety of the system is CO2 and  conservation of mass for ‘A’: [ATOT] ¼ [HA] þ [A-]
so the above equation can be simplified to: Stewart employed the fundamental principles of physical
chemistry to derive the factors that must determine [Hþ]. He
CO2 þ H2O 4 Hþþ HCO3-
applied the principles of electroneutrality, conservation of mass,
and the law of mass action (the requirement that all equilibriums
Indeed, it is from this equation that the HendersoneHasselbalch
must be simultaneously satisfied) to the various components
equation is derived:
which constitute body fluids:
pH ¼ pK þ log [(HCO3-)/(aPCO2)] so, pH is a function of
 Water
HCO3-/PCO2
 Weak ions are produced from substrates that only partially
The HendersoneHasselbalch equation forms the basis of the
dissociate when dissolved in water. They can be classified
traditional approach to acidebase balance: it is used to show
into two groups:
that, for the CO2/HCO3- buffer system to be sustainable, the body
1) carbon dioxide and associated ions (volatile).
must ultimately regulate HCO3- and PCO2.
2) weak acids (non-volatile) which are mainly protein and
It has therefore been taught that the longer-term control of
inorganic phosphate.
acidebase homeostasis is achieved by respiratory control of
 Strong ions are fully dissociated in biological solutions
plasma PCO2, through changes in alveolar ventilation (occurs
(e.g. Naþ, Kþ, Cl-, lactate); that is their dissociation equi-
over minutes), and by the control of HCO3- excretion by the
libria have a pK far removed from the local pH.
kidneys (occurs over hours to days). Importantly, the traditional
Stewart created a model of human solutions by adding each of
approach views these two variables as independently adjusted
these constituents in turn and solving simultaneous equations
factors that ultimately determine pH.
based on the dissociation equilibria of all the reactions involving
Hþ. In his analysis, he emphasized that the concentrations of the
Carbamino compounds
various chemical species present are the variables of the system,
Carbamino compounds are produced by the combination of CO2 which can be of two types:
with the terminal amine groups of proteins. This reaction occurs
with both intracellular and extracellular proteins, the most sig- Dependent variables have values that are determined internally
nificant one being haemoglobin. Both haemoglobin and by the system. They are determined by the equations (chemical
equilibria) which determine the system and can be altered only
by changes on the values of the independent variables.
Buffer systems in the body
Independent variables have values that are determined by
Extracellular Intracellular
processes or conditions which are external to the system; they
are imposed on the system rather than being determined by it.
C Bicarbonate/carbonic acid C Haemoglobin buffer (Hb-H/Hb-
From his analysis, Stewart showed that [Hþ] in a physio-
buffer system and OxyHb-H/OxyHb-)
logical solution is in fact a function of three independent
C Plasma proteins C Phosphate (H2PO4/HPO4)
variables:
C Intracellular proteins
 The strong ion difference (SID): the total concentration of
Table 1 fully dissociated cations in solution minus the total

ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:5 328 Ó 2024 Published by Elsevier Ltd.
 PHYSIOLOGY

concentration of fully dissociated anions in solution H2O. Due to the concentration gradient, CO2 readily crosses into
¼ {[ Naþ] þ [Kþ] þ [Ca2þ] þ [Mg2þ]} - {[ Cl-] þ the cell through aquaporins where it disassociates back to Hþ
[lactate- ]} ¼ [Naþ] þ [Kþ] - [Cl-] controlled by the kidney. and HCO3. The Hþ is recycled into the lumen whereas HCO3- is
 Total concentration of weak acid ([ATOT]): predominately moved by a Naþ/HCO3- co-transporter into the interstitial fluid
phosphate and proteins such as albumin (controlled by the and returned to the blood (Figure 1).
liver) and Hb (controlled by the haematopoietic system). The remaining HCO3- will pass through the loop of Henle to
 PCO2: controlled by the lungs. the distal convoluted tubule, where most of it is reabsorbed. Here
Therefore, in each body fluid compartment, any changes in pH the cellular excretion of Hþ is driven by Hþ/Kþ-ATPase and an
must be because of a change in one of more of these independent aldosterone-dependent Naþ/Hþ exchange. The body can modify
variables. Crucially, it is misleading of the traditional approach to the pH of urine from pH 8 to pH 4.5. However, even at maximum
think of HCO3- as being specifically regulated to manipulate pH as acidification (0.003 mmol/litre Hþ), only a small proportion of
HCO3- cannot be individually or primarily altered. Stewart the Hþ can be cleared in its free form. Remaining Hþ is cleared
concluded that [HCO3- ] is a marker for acidebase disturbances fixed to the titratable acids: phosphoric acid, uric acid, citric acid
rather than a causative factor. or to ammonium. The presence of the titratable acids in the
The Stewart approach and the traditional approach both agree filtrate, binds free Hþ and maintains the concentration gradient
on the role of the lungs in regulating acidebase balance through for Hþ across the cellular membrane, enabling further HCO3-
CO2 excretion and manipulation of arterial PCO2. However, it is production and transfer back into the body.
the role of the kidney that is disputed. Using the Stewart approach, Unbuffered Hþ cannot account for much acid loss, because
we can discover the true mechanisms by which the kidney regu- the minimum urinary pH is only about 4.5. Thousands of litres of
lates plasma pH and can appreciate key misconceptions that have pH 4.5 urine would have to be excreted to deal with the daily
been propagated because of the traditional approach. non-volatile acid load. The alternative is for the secreted Hþ to
bind to urinary buffers of which phosphate is the most important
Effects of acidebase on respiration control and present in the most significant concentrations. At the pre-
vailing pH values in most biological systems, monohydrogen
CO2 is exhaled from the lungs. With the law of mass action and the
phosphate (HPO42-) and dihydrogen phosphate (H2PO4-) are the
rate of the reaction being proportional to the product of the con-
present species:
centrations of each reactant, Hþ clearance will match that of CO2.
The chemosensitive area located in the medullary ventral surface is
Hþ þ HPO42- 4 H2 PO4-
highly sensitive to CO2 and hydrogen ions. The concentration of
CO2 and Hþ in the blood has an indirect effect on the brainstem’s
The pKa of this reaction is 6.8. Under normal conditions the pH
respiratory centre through this pathway. As Hþ cannot normally
of the glomerular ultrafiltrate is 7.4 (that of plasma), meaning
cross the bloodebrain barrier to the chemosensitive area, it is
that phosphate will initially be predominantly in the mono-
the CO2 that crosses the bloodebrain barrier rapidly reacting with
hydrogen form and so can combine with more Hþ in the renal
H2O to form Hþ. In the normal physiological range, there is a steep
liner response to an increasing PCO2. Alveolar ventilation will
increase by 1e2 litres a minute for each 0.1 kPa increase in PCO2.
This response is not mirrored with changes in the normal range
of pH, with only a tenth of the increase in comparison.

Role of the kidneys in regulation of plasma pH

Non-volatile acids are produced in the body from sources other
than carbon dioxide. They can be produced from an incomplete
metabolism of carbohydrates, fats and proteins. Unlike the volatile
acid, carbonic acid and the carbon dioxide excretion through the
lungs. The kidneys are responsible for the excretion of the non-
volatile acids. These are produced by the metabolism of amino
acids. With a dietary intake of 70 g of protein, metabolism of the
amino acids will produce 190 mmol of non-volatile acids:
 Methionine and cystine: ureaþCO2þH2SO4 4 2Hþ þSO42-
Most of this acid is used in the breakdown and recycling of
organic anions (glutamate, aspartate and lactate), and the
remaining 40e80 mmol/day must be excreted by the kidneys.
The reabsorption of HCO3- is of more significance to the body.
Every day more than 4000 mmol are filtered into the glomerular
lumen, 80e90% is reabsorbed in the proximal convoluted tu-
bule. HCO3- is not readily reabsorbed across the cell membrane,
but the cells of the PCT can excrete Hþ into the lumen via a Naþ/
Hþ co-transporter. The co-transporter, under the action of a
membrane bound carbonic anhydrase, react to form CO2 and Figure 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:5 329 Ó 2024 Published by Elsevier Ltd.
 PHYSIOLOGY

tubules. However, the capacity of the phosphate buffer system is mRNA involved in its transcription is more stable under acidotic
limited under acidotic conditions for two reasons. Firstly, the conditions. Glutamine enters the cell from both the peritubular
amount of phosphate present in the distal tubule cannot be capillaries (80%) and the filtrate (20%). The majority of the
varied significantly. Secondly, as the urinary pH falls to less than ammonium is involved in a process known as ‘medullary cycling’,
5.5 the phosphate buffer system will become fully saturated. that maintains an increasing interstitial concentration of ammo-
Although ‘titratable acidity’ is an important part of excretion of nium from cortex to medulla and low concentrations of ammonium
non-volatile acids under normal circumstances, it is unable to in the distal tubule fluid (analogous to the sodium chloride osmo-
cope when increased renal Hþ excretion is required. lality gradient from cortex to medulla, using a similar kind of
It is a common misconception that ammonia (NH3) provides counter-current multiplication). A model of ammonium handling
this extra urinary buffer capacity: it is thought that lipid-soluble and excretion by the kidney is shown in Figure 2. The ammonium
NH3 is produced in the tubular cell and diffuses into the tubular produced in the proximal tubule cells is secreted into the tubular
fluid where it is effectively trapped by buffering secreted Hþ and lumen by replacing Hþ on the Naþ/Hþ exchanger. This proximally
being converted to water-soluble ammonium (NH4þ). However, produced ammonium is reabsorbed from the tubular fluid in the
this must be incorrect as the pKa for ammonia is so high at 9.2. medulla as it passes along the thick ascending limb of the loop of
This means at both extracellular and intracellular pH, it is present Henle, by replacing Kþ on the triple transporter Naþ/Kþ/2Cl-. This
almost entirely in the acid form NH4þ, and this form is not a means that the amount of ammonium entering the distal tubule is
useful buffer. Under acidotic conditions, it is ammonium (NH4þ) small. Some of the interstitial ammonium returns to the late
excretion itself that fulfils this regulatory role. Unlike phosphate, proximal tubule and enters the medulla again (i.e. recycling oc-
ammonium excretion can increase markedly as urine pH falls. To curs). The net effect is that there is a large ammonium concentra-
understand the physiology of this mechanism, it is vital to adopt tion gradient between the medullary interstitium and the luminal
the Stewart approach. fluid of the medullary collecting duct.
This provides a mechanism by which the amount of ammo-
nium excretion can be highly regulated simply by altering the
Ammonium excretion
permeability of the collecting duct to ammonium (This is anal-
Ammonium is produced predominantly within the proximal tubule ogous to how antidiuretic hormone regulates water homeostasis
cells from glutamine by the action of the enzyme glutaminase. The by altering the collecting duct water permeability). The molec-
expression of glutaminase is controlled by the prevailing pH, the ular mechanisms for this process are only just being elucidated,

Schematic representation of ammonium handling and excretion by the kidney

Glutamine Expression is
Glutaminase
HCO3– pH sensitive

Increasing
NH4+
interstitial
ammonium
Na+ NH4+
Lumen

Interstitium 2Cl–
Na+
NH4+ NH4+ NH4+
2Cl –
Na+
NH4+

RhCG
NH4+

NH4+
Expression is
NH4+ pH sensitive
medullary
NH4+ accumulation NH +
4

Figure 2

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 PHYSIOLOGY

but it seems that specific membrane proteins from the family of an elegant example of how changes in the SID disturb acidebase
Rhesus glycoproteins play an important role in regulating the balance. Saline does not contain any significant quantity of Hþ
transport of ammonium down its concentration gradient into the ions and therefore by the traditional approach it would not be ex-
collecting duct. pected to alter pH. While it is true that the pH of saline solution may
Importantly, this mechanism is pH sensitive: it has been be 6, which in physiological terms is too acidic to sustain life, the
shown that the expression of the Rhesus C glycoprotein Hþ load it presents is trivial. If Hþ was the only consideration, we
(RhCG) in the collecting duct increases in the presence of a would need to administer 1000 litres of saline to increase a patient’s
prolonged metabolic acidosis, leading to increased ammonium ‘base deficit’ by just 1 mmol/litre. However, saline is a ‘SID zero’
excretion. solution, and thus causes the extracellular fluid SID to decrease:
How can ammonium excretion correct a metabolic acidosis? saline causes [Cl-] to increase proportionally more than [Naþ] as Cl-
The excretion of NH4þ does not excrete any protons in the is normally present at a lower concentration (extracellular [Cl-] ¼
traditional sense. However, NH4þ is a weak anion that when 110 mM; extracellular [Naþ] ¼ 140 mM). This causes a relative
excreted is accompanied by Cl-, allowing the body to retain the hyperchloraemia and a decrease in the SID, with a subsequent
strong ions of Naþ and Kþ. It is this excretion of Cl- without an acidosis. In contrast, Hartmann’s solution has a SID much closer to
equivalent amount of strong ion that is the true cause of the the SID of extracellular fluid and thus does not have as profound an
correction of plasma pH, as it results in an increase in the strong effect on plasma pH.
ion difference.
Metabolic alkalosis is a process caused by either an increase in
the SID, or a decrease in [ATOT]. An increase in the SID may be
Classification of acidebase disturbances using the caused by the loss of more strong anions than strong cations (as
Stewart approach with diuretic therapy, or from the loss of Cl- following vomiting
As discussed, the Stewart approach shows that disturbances in of gastric secretions in pyloric stenosis or nasogastric aspiration)
plasma pH can occur only via changes in the independent vari- or by the administration of more strong cations than strong an-
ables: pCO2, the SID, and [ATOT]. ions (as with infusion of NaHCO3 or large volumes of blood
Therefore, as with the traditional approach, respiratory containing sodium citrate). A decrease in [ATOT] can result from
acidosis or alkaloses are those in which the primary disturbance causes of hypoalbuminaemia such as nephrotic syndrome or in
is the PCO2. However, for metabolic acidosis and alkalosis, liver failure.
whereas the traditional approach focuses on primary distur-
bances in HCO3-, the Stewart approach shows that the true pri- Conclusion
mary disturbance must in fact be in the SID or [ATOT]. Primary
In the words of Stewart, the conventional understanding of
respiratory disturbances are compensated by metabolic re-
acidebase balance is ‘cluttered with jargon, chemically mean-
sponses, and primary metabolic disturbances are compensated
ingless derived equations, a misunderstanding of what is really
by respiratory responses.
happening, and an artificial use of the HendersoneHasselbalch
equation as the only equation determining acidebase balance
Respiratory acidosis is a process caused by a rise in arterial
in any body fluid’. This article has emphasized how the Hþ and
PCO2 which is proportional to VCO2/VA (where VCO2 is the
HCO3- concentrations are dependent variables, whose values
amount of CO2 produced by the body and VA is alveolar venti-
are determined by the SID, [ATOT] and pCO2: movement of Hþ
lation). Therefore, respiratory acidosis occurs during alveolar
or HCO3- cannot affect plasma Hþ or HCO3- concentrations
hypoventilation (e.g. asphyxia, neuromuscular disease, chronic
unless changes in the independent variables also occur.
pulmonary disease, opiate toxicity) or increased CO2 production
Although the traditional approach remains the most widely
by the body (e.g. during exercise, malignant hyperthermia).
used in everyday clinical practice, it fails to understand the true
mechanisms of acid-base disorders and pH homeostasis. A
Respiratory alkalosis is a process caused by a fall in arterial PCO2
and is always due to alveolar hyperventilation (e.g. excessive
minute ventilation if mechanically ventilated, physiological FURTHER READING
response to hypoxia, anxiety attacks, salicylate intoxication). Brandis K. Acid-Base Physiology. 2015. Available from: http://www.
anaesthesiamcq.com/AcidBaseBook/ABindex.php
Metabolic acidosis is a process caused by either a decrease in the Hickish T, Farmery AD. Acid-base physiology. Anaesth Intensive Care
SID, or by an increase in [ATOT]. A decrease in the SID may be Med 2021; 22: 422e7.
caused by either the generation of organic strong anions (e.g. Kellum JA, Elbers PWG. Stewart’s textbook of acid-base. 2nd edn.
lactate following a hypoxic insult, or ketone bodies in diabetic UK: Lulu Enterprises Ltd, 2018.
ketoacidosis), by the loss of strong cations (as with the loss of Kþ Shaw I, Gregory K. Acid-base balance: a review of normal physiology.
and Naþ in severe diarrhoea), by the mishandling of strong ions (as BJA Educ 2022; 22: 396e401.
with renal tubular acidosis), or by the addition of exogenous strong Sirker AA, Rhodes A, Grounds RM, et al. Acid-base physiology: the
anions (as with iatrogenic acidosis or poisoning). The iatrogenic traditional and the modern approaches. Anaesthesia 2002; 57:
metabolic acidosis that results from the infusion of saline provides 348e56.

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