Replenishing Alkali During Hemodialysis: Physiology-Based Approaches.

The acid-base goal of intermittent hemodialysis is to replenish buffers consumed by endogenous acid production and expansion acidosis in the period between treatments. The amount of bicarbonate needed to achieve this goal has traditionally been determined empirically with a goal of obtaining a reasonable subsequent predialysis blood bicarbonate concentration ([HCO3 - ]). This approach has led to very disparate hemodialysis prescriptions around the world. The bath [HCO3 - ] usually chosen in the United States and Europe causes a rapid increase in blood [HCO3 - ] in the first 1-2 hours of treatment, with little change thereafter. New studies show that this abrupt increase in blood [HCO3 - ] elicits a buffer response that removes more bicarbonate from the extracellular compartment than is added in the second half of treatment, a futile and unnecessary event. We propose that changes in dialysis prescription be studied in an attempt to moderate the initial rate of increase in blood [HCO3 - ] and the magnitude of the body buffer response. These new approaches include either a much lower bath [HCO3 - ] coupled with an increase in the bath acetate concentration or a stepwise increase in the bath [HCO3 - ] during treatment. In a subset of patients with low endogenous acid production, we propose reducing the bath [HCO3 - ] as the sole intervention.

Hemodialysis using a low bicarbonate dialysis bath: Implications for acid-base homeostasis.

The low bath bicarbonate concentration ([ HCO3- ]) used by a nephrology group in Japan (25.5 mEq/L), coupled with a bath [acetate] of 8 mEq/L, provided an opportunity to study the acid-base events occurring during hemodialysis when HCO3- flux is from the patient to the bath. We used an analytic tool that allows calculation of HCO3- delivery during hemodialysis and the physiological response to it in 17 Japanese outpatients with an average pre-dialysis blood [ HCO3- ] of 25 mEq/L. Our analysis demonstrates that HCO3- addition is markedly reduced and that all of it comes from acetate metabolism. The HCO3- added to the extracellular fluid during treatment (19.5 mEq) was completely consumed by H+ mobilization from body buffers. In contrast to patients dialyzing with higher bath [ HCO3- ] values in the US and Europe, organic acid production was suppressed rather than stimulated. Dietary analysis indicates that these patients are in acid balance due to the alkaline nature of their diet. In a larger group of patients using the same bath solution, pre-dialysis blood [ HCO3- ] was lower, 22.2 mEq/L, but still in an acceptable range. Our studies indicate that a low bath [ HCO3- ] is well tolerated and can prevent stimulation of organic acid production.

CO2 reactivity with Mg2NiH4 synthesized by in situ monitoring of mechanical milling.

CO2 capture and conversion are a key research field for the transition towards an economy only based on renewable energy sources. In this regard, hydride materials are a potential option for CO2 methanation since they can provide hydrogen and act as a catalytic species. In this work, Mg2NiH4 complex hydride is synthesized by in situ monitoring of mechanical milling under a hydrogen atmosphere from a 2MgH2:Ni stoichiometric mixture. Temperature and pressure evolution is monitored, and the material is characterized, during milling in situ, thus providing a good insight into the synthesis process. The cubic polymorph of Mg2NiH4 (S.G. Fm3[combining macron]m) starts to be formed in the early beginning of the mechanical treatment due to the mechanical stress induced by the milling process. Then, after 25 hours of milling, Mg2NiH4 with a monoclinic (S.G. C12/c1) structure appears. The formation of the monoclinic polymorph is most likely related to the stress release that follows the continuous refinement of the material's microstructure. At the end of the milling process, after 60 hours, the as-milled material is composed of 90.8 wt% cubic Mg2NiH4, 5.7 wt% monoclinic Mg2NiH4, and 3.5 wt% remnant Ni. The as-milled Mg2NiH4 shows high reactivity for CO2 conversion into CH4. Under static conditions at 400 °C for 5 hours, the interactions between as-milled Mg2NiH4 and CO2 result in total CO2 consumption and in the formation of the catalytic system Ni-MgNi2-Mg2Ni/MgO. Experimental evidence and thermodynamic equilibrium calculations suggest that the global methanation mechanism takes place through the adsorption of C and the direct solid gasification towards CH4 formation.

Changing dialysate composition to optimize acid-base therapy.

In response to rapid alkali delivery during hemodialysis, hydrogen ions (H+ ) are mobilized from body buffers and from stimulation of organic acid production in amounts sufficient to convert most of the delivered bicarbonate to CO2 and water. Release of H+ from nonbicarbonate buffers serves to back-titrate them to a more alkaline state, readying them to buffer acids that accumulate in the interval between treatments. By contrast, stimulation of organic acid production only serves to remove added bicarbonate (HCO3 - ) from the body; the organic anions produced by this process are lost into the dialysate, irreversibly acidifying the patient as well as diverting metabolic activity from normal homeostasis. We have developed an analytic tool to quantify these acid-base events, which has shown that almost two-thirds of the H+ mobilized during hemodialysis comes from organic acid production when bath bicarbonate concentration ([HCO3 - ]) is 32 mEq/L or higher. Using data from the hemodialysis patients we studied with our analytical model, we have simulated the effect of changing bath solute on estimated organic acid production. Our simulations demonstrate that reducing bath [HCO3 - ] should decrease organic acid production, a change we propose as beneficial to the patient. They also highlight the differential effects of variations in bath acetate concentration, as compared to [HCO3 - ], on the amount and rate of alkali delivery. Our results suggest that transferring HCO3 - delivery from direct influx to acetate influx and metabolism provides a more stable and predictable rate of HCO3 - addition to the patient receiving bicarbonate-based hemodialysis. Our simulations provide the groundwork for the clinical studies needed to verify these conclusions.

Evaluation of the formation and carbon dioxide capture by Li4SiO4 using in situ synchrotron powder X-ray diffraction studies.

Carbon capture and storage using regenerable sorbents are an effective approach to reduce CO2 emissions from stationary sources. In this work, lithium orthosilicate (Li4SiO4) was studied as a carbon dioxide sorbent. For a deeper understanding of the synthesis and carbonation mechanism of Li4SiO4, an in situ synchrotron radiation powder X-ray diffraction technique was used. The Li4SiO4 powders were synthesized by a combination of ball milling of a Li2CO3 and SiO2 mixture followed by a thermal treatment process at low temperature. In situ studies showed that formation of Li4SiO4 from the as-milled 2Li2CO3-SiO2 mixture involves decomposition of Li2CO3 by reaction with SiO2via Li2SiO3 as an intermediate compound. No evidence of Li2Si2O5 formation was obtained, in spite of thermodynamic predictions. The CO2 capture by Li4SiO4 was evaluated dynamically over a wide temperature range, reaching a maximum weight increase of 34 wt% and good cyclability after about 10 cycles. By thermogravimetric and microstructural analyses in combination with ex situ and in situ measurements, a two step carbonation mechanism and its influence on the final CO2 capture was clearly elucidated. Under dynamical conditions up to 700 °C, the lower number of Li2CO3 nuclei initially formed retards the double shell formation and the nucleation and growth of the Li2CO3 particles remains the controlling step up to higher CO2 capture capacity. Isothermal carbonation at 700 °C favours the formation of a higher number of Li2CO3 nuclei that creates a thin carbonate shell. The CO2 diffusion through this shell is the limiting step from the beginning and further carbonation is hindered as the reaction progresses.

Improvements in the hydrogen storage properties of the Mg(NH2)2-LiH composite by KOH addition.

Potassium-containing compounds, such as KH, KOH, KNH2 and different potassium halides, have shown positive effects on the dehydrogenation properties of the Li-Mg-N-H system. However, it is still discussed whether the K-compounds modify the thermodynamics of the system or if they have only a catalytic effect. In this work the impact of the addition of two K-containing compounds (0.08 mol% of KCl and KOH) on the hydrogen storage performance of the Mg(NH2)2-LiH composite was studied. The KOH incorporation reduced the dehydrogenation temperature from 197 °C to 154 °C, beginning the process at low temperature (∼70 °C). The doped sample was able to reversibly absorb and desorb 4.6 wt% of hydrogen with improved kinetics; dehydrogenation rates were increased four times, whereas absorptions required 20% less time to be completed in comparison to the pristine material. The thermodynamic destabilization of the Mg(NH2)2-2LiH composite by the addition of a small amount of KOH was demonstrated by an increment of 30% in the dehydrogenation equilibrium pressure. According to detailed structural investigations, the KH formed by the KOH decomposition through milling and thermal treatment, can replace LiH and react with Mg(NH2)2 to produce a mixed potassium-lithium amide (Li3K(NH2)4). The KH role is not limited to catalysis, but rather it is responsible for the thermodynamic destabilization of the Mg(NH2)2-LiH composite and it is actively involved in the dehydrogenation process.

Acid-base homeostasis during hemodialysis: New insights into the mystery of bicarbonate disappearance during treatment.

In patients receiving hemodialysis, it has long been recognized that much more bicarbonate is delivered during treatment than ultimately appears in the blood. To gain insight into this mystery, we developed a model that allows a quantitative analysis of the patient's response to rapid alkalinization during hemodialysis. Our model is unique in that it is based on the distribution of bicarbonate in the extracellular fluid and assesses its removal from this compartment by mobilization of protons (H+ ) from buffers and other sources. The model was used to analyze the pattern of rise in blood bicarbonate concentration ([HCO3- ]), calculated from measurements of pH and PCO2 , in patients receiving standard bicarbonate hemodialysis. Model analysis demonstrated two striking findings: (1) 35% of the bicarbonate added during hemodialysis was due to influx and metabolism of acetate, despite its low concentration in the bath solution, because of the rapidly collapsing gradient for bicarbonate influx. (2) Almost 90% of the bicarbonate delivered to the patients was neutralized by H+ generation. Virtually all the new H+ came from intracellular sources and included both buffering and organic acid production. The small amount of added bicarbonate retained in the extracellular fluid increased blood [HCO3- ], on average, by 6 mEq/L in our patients. Almost all this rise occurred during the first 2 hours. Thereafter, blood [HCO3- ] changed minimally and always remained less than bath [HCO3- ]. This lack of equilibrium was due to the continued production of organic acid. Release of H+ from buffers is a reversible physiological response, restoring body alkali stores. By contrast, organic acid production is an irreversible process during hemodialysis and is metabolically inefficient and potentially catabolic. Our analysis underscores the need to develop new approaches for alkali repletion during hemodialysis that minimize organic acid production.

Acid-base assessment of patients receiving hemodialysis. What are our management goals?

Acid-base assessment of patients receiving conventional hemodialysis (HD) has been based solely on predialysis serum [total CO2 ], and treatment is currently driven by the KDOQI guideline from 2000. This guideline was directed solely at minimizing metabolic acidosis and thereby improving bone and muscle metabolism. In 2000, no data were available to assess the effects of acid-base status on morbidity and mortality. Since then, new data have emerged from several large cohort studies about the association between variations in predialysis serum [total CO2 ], as well as blood pH, and morbidity and mortality risk. These studies have shown increased risk not only with very low predialysis [total CO2 ] values, but also with predialysis alkaline pH and very high predialysis serum [total CO2 ] values. At present, our major concern is not for patients with metabolic acidosis, but rather for the growing numbers of patients with metabolic alkalosis. This review discusses the controversies around assessing and treating acid-base status in HD patients, and recommends a practical approach based on the results of these recent studies. The new approach provides recommendations for patients both with very low and very high predialysis serum [total CO2 ] values.

Clarifying the dehydrogenation pathway of catalysed Li4(NH2)3BH4-LiH composites.

The effect of different metal oxides (Co3O4 and NiO) on the dehydrogenation reaction pathways of the Li4(NH2)3BH4-LiH composite was investigated. The additives were reduced to metallic species i.e. Co and Ni which act as catalysts by breaking the B-H bonds in the Li-B-N-H compounds. The onset decomposition temperature was lowered by 32 °C for the Ni-catalysed sample, which released 8.8 wt% hydrogen below 275 °C. It was demonstrated that the decomposition of the doped composite followed a mechanism via LiNH2 and Li3BN2 formation as the end product with a strong reduction of NH3 emission. The sample could be partially re-hydrogenated (∼1.5 wt%) due to lithium imide/amide transformation. To understand the role of LiH, Li4(NH2)3BH4-LiH-NiO and Li4(NH2)3BH4-NiO composites were compared. The absence of LiH as a reactant forced the system to follow another path, which involved the formation of an intermediate phase of composition Li3BN2H2 at the early stages of dehydrogenation and the end products LiNH2 and monoclinic Li3BN2. We provided evidence for the interaction between NiO and LiNH2 during heating and proposed that the presence of Li facilitates a NHx-rich environment and the Ni catalyst mediates the electron transfer to promote NHx coupling.

Beyond bicarbonate: complete acid-base assessment in patients receiving intermittent hemodialysis.

Background: Acid-base assessments in hemodialysis patients have been limited almost entirely to measurements of total CO 2 concentration, and assumptions have been made about the presence of acid-base disorders. To gain a fuller understanding of the acid-base status of stable hemodialysis patients, we analyzed measurements of pCO 2 , pH and HCO 3 - obtained in a cohort of chronic stable hemodialysis patients over a 5-year period. Methods: We reviewed acid-base measurements taken pre-dialysis from fistula blood in 53 outpatients receiving hemodialysis thrice weekly between 2008 and 2012. In these patients, pH and pCO 2 were measured using an onsite blood gas analyzer, and HCO 3 - was computed. Relevant clinical and laboratory data were obtained from medical records. Factors affecting serum HCO 3 - were identified. Simple and mixed acid-base disorders were diagnosed using accepted rules. Results: Serum HCO 3 - was affected by age, normalized protein catabolic rate, interdialytic weight gain and length of interval between treatments. As expected, metabolic acidosis was the most common acid-base disorder, but respiratory acid-base disturbances, as simple or complex disorders, were found in 41% of the measurements. Respiratory alkalosis was seen more frequently than respiratory acidosis, but the latter disorder was more commonly associated with serious comorbidities. Conclusions: Respiratory acid-base disorders are an important component of the acid-base abnormalities seen in hemodialysis patients and are not identified by measuring total CO 2 concentration; hence, complete acid-base measurements are needed to determine the components of hemodialysis patients' acid-base status that are contributing to mortality risk.

Effective participation of Li4(NH2)3BH4 in the dehydrogenation pathway of the Mg(NH2)2-2LiH composite.

Lithium fast-ion conductors have shown positive effects on the hydrogen storage properties of the Li-Mg-N-H system. In the present work, Li4(NH2)3BH4 doped Mg(NH2)2-2LiH was formed by milling the 2LiNH2-MgH2-0.2LiBH4 composite and posterior annealing under hydrogen pressure to reduce the kinetic barrier of the Li-Mg-N-H system. The effect of repetitive dehydrogenation/rehydrogenation cycles on the kinetic and thermodynamic performance was evaluated. The dehydrogenation rate in the doped composite was twice that in the un-doped sample at 200 °C, while hydrogenation was 20 times faster. The activation energy decreases by 9% due to the presence of Li4(NH2)3BH4 compared to the un-doped composite, evidencing its catalytic role. The presence of Li4(NH2)3BH4 in the composite stabilized the hydrogen storage capacity after successive sorption cycles. Thermodynamic studies revealed a variation in the pressure composition isotherm curves between the first dehydrogenation cycle and the subsequent. The Li4(NH2)3BH4 doped composite showed a sloped plateau region at higher equilibrium pressure in regard to the flat plateau of the un-doped composite. Detailed structural investigations revealed the effective influence of Li4(NH2)3BH4 in different reactions: the irreversible dehydrogenation in the presence of MgH2 and the reversible hydrogen release when it reacts with Li2Mg2(NH)3. The role of Li4(NH2)3BH4 in improving the dehydrogenation kinetics is associated with the weakening of the N-H bond and the mobile small ion mass transfer enhancement.

New amide-chloride phases in the Li-Al-N-H-Cl system: formation and hydrogen storage behaviour.

New amide-chloride phases were successfully synthesized by mechanical milling of the LiNH2-AlCl3 mixture at a molar ratio of 1 : 0.11 and further heating at 150 °C under argon (0.1 MPa) or under hydrogen pressure (0.7 MPa). Powder X-ray diffraction measurements as a function of milling time increase revealed that the milling of the LiNH2-0.11AlCl3 mixture results in the formation of a FCC solid solution with an excess of LiNH2. Subsequent heating of the LiNH2-0.11AlCl3 sample ball milled for 5 hours at 150 °C under argon or under hydrogen induces the appearance of an amide-chloride phase isostructural with cubic Li4(NH2)3Cl. This Li-Al-N-H-Cl phase transforms progressively into the trigonal phase after prolonged heating at 300 °C under hydrogen pressure. The thermal behaviour of the amide-chloride without and with LiH addition displays dissimilar decomposition pathways. The decomposition of amide-chloride alone involves the formation of ammonia and hydrogen from 120 to 300 °C. Conversely, the amide-chloride material in the presence of LiH only releases hydrogen avoiding the emission of ammonia. The resultant material is able to be rehydrogenated under moderate conditions (300 °C, 0.7 MPa H2), providing a new reversible hydrogen storage system.

Approach to the hemodialysis patient with an abnormal serum bicarbonate concentration.

We present a patient receiving hemodialysis with a persistently high serum bicarbonate concentration to illustrate the evaluation and management issues for patients with both high (>25 mEq/L) and low (<20 mEq/L) pretreatment values. Patients with high serum bicarbonate concentrations typically are malnourished and have low rates of endogenous acid production. Evaluation should begin with assessment of whether an acute and potentially reversible cause of metabolic alkalosis is present. If not, management should be directed at treating malnutrition. By contrast, patients with low predialysis serum bicarbonate concentrations, in the absence of an acute and reversible cause, may benefit from increasing the level by an adjustment in dialysate bicarbonate concentration. However, the level at which one should intervene and to what extent serum bicarbonate concentration should be increased are unresolved issues. Whether such an intervention will reduce mortality risk has not been determined.

Severe hypokalemia in a patient with subarachnoid hemorrhage.

Hypokalemia is a common electrolyte disorder in the intensive care unit. Its cause often is complex, involving both potassium losses from the body and shifts of potassium into cells. We present a case of severe hypokalemia of sudden onset in a patient being treated for subarachnoid hemorrhage in the surgical intensive care unit in order to illustrate the diagnosis and management of severe hypokalemia of unclear cause. Our patient received agents that promote renal potassium losses and treatments associated with a shift of potassium into cells. We outline the steps in diagnosis and management, focusing on the factors regulating the transcellular distribution of potassium in the body.