effects of alkalosis on plasma concentration excretion of

Journal of Clinical InvestigationVol. 43, No. 1, 1964

Effects of Alkalosis on Plasma Concentration and UrinaryExcretion of Inorganic Phosphate in Man*MARVOUS E. MOSTELLAR t AND ELBERT P. TUTTLE, JR.$

(From the Department of Medicine, Renal and Electrolyte Section, Emory University Schoolof Medicine at Grady Memorial Hospital, Atlanta, Ga.)

In 1924, Haldane, Wigglesworth, and Wood-row reported on the effect of reaction changes onhuman inorganic metabolism (1). They foundthat respiratory alkalosis caused a sharp fall andrespiratory acidosis a sharp rise in serum phos-phorus concentration. They also examined meta-bolic changes induced by oral ingestion of Na-HCO3 or NH4Cl for several days, but respiratorycompensation would have minimized pH changesunder the conditions of their experiments. Theyfound no significant deviation of serum phosphorusfrom normal values. The influence of alkalosison serum and urinary phosphorus has been in-termittently observed since that time during ex-periments on hydrogen ion disturbances in dogsand in man (2-9). However, most recent re-views on phosphorus metabolism and the para-thyroids do not mention the effect of blood hy-drogen ion concentration or carbon dioxide ten-sion upon the concentration of phosphorus in theserum or upon the urinary excretion and clearanceof phosphorus (10-22).Our study was undertaken to evaluate the range

of variation of plasma phosphorus concentrationunder the influence of elevated blood pH, to as-certain whether hydrogen ion concentration orCO2 content is the critical determinant, and toconsider possible explanations for the fall in con-centration of phosphorus.

* Submitted for publication July 10, 1963; acceptedSeptember 30, 1963.Presented at the national meeting of the American

Federation for Clinical Research, April 30, 1961, AtlanticCity, N. J.

Supported by U. S. Public Health Service grantsH-4191 (C 1) and A-5002 Met (1).

t This work was done during tenure of a postdoctoralresearch fellowship of the National Institutes of Health,Bethesda, Md.

t Holder of the Georgia Heart Association Chair ofCardiovascular Research, Emory University School ofMedicine.

Methods

Sixteen experiments were performed between 8 a.m.and 2 p.m. in eleven healthy young adults from 20 to 40years of age. Three major experimental designs wereused. In six experiments respiratory alkalosis was in-duced by voluntary hyperventilation. The Pco2 of ex-pired air was monitored with a continuous infrared CO2analyzer. Breathing was controlled to reduce the end-expiratory Pco2 from a control range of 35 to 40 mmHg to a range of 13 to 20 mm Hg.

In four experiments hyperventilation without alka-losis was studied as a control. Two of these were con-ducted with a Bird Mark VIII respirator using bothpositive and negative pressures. After a control periodof selfregulated respiration, hyperventilation was inducedby increase in rate and depth of exchange. The in-spired gas mixture was adj usted to contain sufficientCO2 to maintain end-expiratory Pco2 at control levels.After stabilization under these conditions, CO2 was re-moved from the inspired gas mixture, and respiratoryalkalosis was induced. In two further experiments vol-untary active hyperventilation was carried out in a tentreceiving 10%o CO2 and 90% 02 so that end-expiratoryPco2 was maintained at control levels.

In six other experiments, metabolic alkalosis was in-duced. NaHCO2, in amounts from 3.5 to 4.5 mEq per kgbody weight, was given intravenously over a 30-minute pe-riod in a concentration approximately five times isotonic,and then an equal amount was begun as a sustaining in-fusion for an additional 90 minutes. Respiration in theseexperiments maintained end-expiratory Pco2 at 40 mmHg or slightly above.

All subjects were fasting, but glucose was infused at arate to provide one calorie per minute throughout theexperiment. Blood was collected anaerobically from aRiley needle in the radial artery in syringes contain-ing measured amounts of heparin sodium. Arterial bloodsbracketing urine specimens were collected during a con-trol period at - 40, - 20, and 0 minutes, during alkalo-sis and recovery at + 60, + 80, and + 100 minutes afterbeginning the periods. Specimens for pH and CO2 wereplaced on ice and analyzed within 1 hour. Specimens forother analyses were centrifuged immediately, and plasmawas separated from the cells. Urines were obtained byvoiding at the end of 20-minute periods. Flow ratesvaried between .5 and 23.4 ml per minute, with a meanflow of 8.5 ml per minute. Flows in seven periods wereless than 3 ml per minute.Whole blood was analyzed for pH, total CO2, and

138

EFFECT OF ALKALOSIS ON INORGANIC PHOSPHATES IN MAN

hematocrit by the technique of Shock and Hastings (23),as modified by Singer, Shohl, and Bluemle (24). Thistechnique utilizes a photometric determination of pH andthe manometric determination of CO2 by the method ofPeters and Van Slyke (25). Blood Pco2 was estimatedfrom the nomogram of Singer and Hastings (26).Plasma, whole blood, and urine inorganic phosphate con-centrations were measured by the method of Fiske andSubbarow (27) and expressed as concentrations ofphosphorus. Sodium and potassium concentrations weremeasured with a flame photometer using lithium as aninternal standard. Creatinine chromogen was measuredin plasma and urine, using a Folin-Wu (28) precipitateand the Jaffe reaction with alkaline picrate as modifiedby Bonsnes and Taussky (29). Serum calcium wasmeasured by titration with EDTA using murexide as anindicator in the manner of Fales (30). Blood glucosewas determined by the method of Somogyi as modifiedby Nelson (31).

All analyses were performed in duplicate from sepa-rate samples of plasma or urine. Urinary clearanceswere calculated using mid-point serum concentrations foreach period. Indexes of analytical precision are listed inthe appendix.

Analysis of variance of the data on serum concentra-tions and renal excretions were carried out according tomethods described by Snedecor (32). Missing valueswere calculated by the least squares method. The datawere considered to belong to the category of mixedModel I and Model II samples. Period (Pi) and bloodspecimens (Bk())within periods were considered fixedeffects, whereas subjects (Sj) were random effects.Symbolically:

Xjk = + P1 + Sj + Bk(i) + (PS) i + (BS) jk(i).

Variance ratios were calculated from the appropriateestimated mean squares and compared with the table of"F" ratios for significance (33). Significant contribu-tions of factor means to the total variance are noted inthe tables. Because of the occurrence of significantsubject-period interactions, no effort was made to quan-titate precisely the significance of differences betweenindividual periods. For purposes of summary, simplestandard deviations for the variables within each ex-perimental period are given.

Results

Respiratory alkalosis. Table I gives analyzedand derived data from the blood in six experimentsduring respiratory alkalosis produced by active hy-perventilation. Figure 1 is a graphic representa-tion of the changes in the plasma and blood. Itshows the characteristic pattern of respiratory al-kalosis with elevation of the mean blood pH from7.42 to 7.65, a fall in the mean whole blood totalCO2 from 20.2 to 13.6 mmoles per L, and a fall inmean whole blood Pco2 as calculated by nomo-

graph from 38 to 16 mm Hg. The stability ofthese variables over the next 40 minutes indicatesa relatively steady state of acid-base relationships.The plasma inorganic phosphorus concentration

shows a consistent fall from a mean of .96 to .29mmole per L and is proportional to the rise in pHof the blood. This is also apparent in the fall of

BLOOD

pH

7.80

7.70

7.60

7.5

7.4 FRESPIRATORY ALKALOSIS -MET OLIC ALKALOSIS-

7.3c-

BLOOD

PCO2 30mmHg 20 _

BLOOD C02 30

CONTENT 20-mM/L .0s

0

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PHOSPHORUS.50

mM/L .25-

0

BLOOD 1,ooINORGANIC .7

PHOSPHORUS 50 -

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PLASMA 2.37-

CALCIUM 225

mM /L

POTASSIUM

2.5-;BLOOD 150

GLUCOSE 'oomqm% 50

01 - 6i0CONTROL

/

.1 +e'o +tI 'EXPERIMENTAL

time in minutes

LI +64'o +Ii0RECOVERY

FIG. 1. PATTERN OF EXPERIMENTAL ALKALOSIS. Bloodor plasma concentrations are plotted against relative time.After the control period, voluntary hyperventilation oran infusion of hypertonic NaHCO3 was begun. Re-covery determinations were begun 60 minutes aftertermination of the alkalotic stimulus.

= H_I

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139

MARVOUS E. MOSTELLAR AND ELBERT P. TUTTLE, JR.

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TABLE II

Urinary excretions in acute respiratory alkalosis

Control period Experimental period Recovery period

Determination Subjects Specimen 1 Specimen 2 Specimen 1 Specimen 2 Specimen 1 Specimen 2

Endogenous 02 159 140 141 81 153 135creatinine 03 192 202 130 132 152 176chromogen 04 115 135 89 123 132 140clearance, 06 149 142 140 152 135ml/min 14 140 130 88 143

15 154 109 186

Mean for specimen 151 150 117 113 153 146Mean for period* 151 115 150SD for period 26 24 18

Phosphorus 02 10.9 9.8 .6 .2 8.6 13.3excretion, 03 3.5 2.7 .2 .2 1.4 4.8lumoles/min 04 10.7 11.9 .2 .1 2.2 6.3

06 10.3 9.2 .1 1.9 5.314 6.0 3.9 .2 11.915 5.9 .2 10.4

Mean for specimen* 8.3 7.2 .3 .2 6.1 7.4Mean for period* 7.7 .2 6.6SD for period 3.4 .1 4.3

*p <.01.

the mean whole blood phosphorus concentrationfrom 1.23 to 0.59 mmole per L.

Plasma calcium, potassium, and blood glucosedid not vary in any consistent manner under thestimulus of respiratory alkalosis.

Table II and Figure 2 show renal excretion dataduring respiratory alkalosis. The renal excretionof P fell from a mean of 7.7 to 0.2 jumole perminute, and the corresponding phosphorus clear-ance fell from a mean of 8.0 to 1.3 ml per minute.During the same period, there was an irregulartendency of the creatinine clearance to fall.

Potassium excretion showed an increase froma mean of 61 ,uEq per minute to 158 /xEq perminute during alkalosis and returned to levelsbelow control (20 uEq per minute) during re-covery.

Effects of hyperventilation without alkalosis.The effects of increased respiratory minute vol-ume induced by voluntary active hyperventilationand by passive positive-negative pressure artificialrespiration with maintenance of normal bloodPco2 and pH are illustrated in Figures 3 and 4.Adequacy of control of pH and Pco2 is evi-

dent in both studies. No quantitative index ofrespiratory or alveolar minute volume is offered,but subjects performing active hyperventilationhad executed the experiment previously and en-deavQred to match their earlier performance,

The magnitude of passive hyperventilation is re-flected in the acute alkalosis induced in the thirdperiod after withdrawal of CO2 from the in-spired gas mixture.

FIG. 2. URINARY EXCRETIONS IN EXPERIMENTAL ALKA-

LOSIS. The lines connect the mid-points of each collectionperiod.

141


7.80

7.70BLOOD

7.60

pH 7.50

7.40

P x.

BLOODPC 02

mmHg-BLOOD C02CONTENT

mM/L

PLASMA

PHOSPHORUS

mM/L

40k

20k--e-02 0 - _==I15

,1.4

1.0-

.5

_________________I___-6'0 +6'0CONTROL HYPERVENTILA-

TION WITH CO2

460 + 20RECOVERY

time in minutes

FIG. 3. ACTIVE HYPERVENTILATION WITHOUT ALKALOSIS.In the experimental period the subjects were placed in a

tent receiving CO2 in an amount to maintain end-expira-tory Pco2 at control levels despite vigorous active hy-perventilation.

BLOOD

pH

7.80

7.70

7.60

7.50

7.4C

7.30BLOOD 40-PCO2 20 _

mmHoBLOOD CO2 20_CONTENT 15-

mM/L

1.4 -

PLASMA 1.0_

PHOSPHORUSmM/L .5

+60 0 .JO . +l _ -I_-do

CONTROL+do 6 +40 + lio

HYPERVENTILA- HYPERVENTILATION

TI1ON WITH CO2 WITHOUT C02time In minutes

FIG. 4. PASSIVE HYPERVENTILATION WITH AND WITH-

OUT CO2. After the control period, a face mask attachedto a Bird Mark VIII respirator was fitted to the sub-ject. CO2 was introduced into the circuit, and the respira-tor was adjusted for regulation of both inspiration andexpiration so that end-expiratory Pco2 was at controllevels. After 80 minutes the CO2 was removed, and thesubjects went into alkalosis without change of respiration.

In three of the four subjects studied, the plasmaphosphorus concentration remained constant or

rose slightly. In the fourth subject a fallingplasma phosphorus concentration noted duringthe control period continued for one period ofhyperventilation without change of rate of falland then leveled off. The third period of passivehyperventilation without added CO2 produced thetypical rise of pH and fall of plasma phosphorusconcentration. These data are not included inthe series of Table I and Figure 1.The effect of prolongation of hyperventilation

with alkalosis on the variables shown in Figure 1and 2 is graphically represented in Figure 5. Af-ter 60 minutes of hyperventilation, a steady stateof alkalosis and hypophosphatemia was reached.Arterial blood glucose showed an unexplained riseat 41 hours. A gradual steady fall in serum Kwas observed.

Phosphorus excretion remained drastically de-

CONTROL EXPERIMENTAL RECOVERYactua lImew

FIG. 5. PROLONGED ACTIVE HYPERVENTILATION WITH

ALKALOSIS. The subject carried out active hyperventila-tion for 320 minutes. The level of hyperventilation was

maintained by monitoring the end-expiratory Pco, withan infrared CO1 analyzer.

142

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METABOLIC ALKALOSIS

CONTROL

EXPERIMENTAL 0RECOVERY X

X X

'. 00

7.40 7.50 7.60

BLOOD pH

RESPIRATORY ALKALOSIS

7.70

CONTROL 0

EXPERIMENTAL 0RECOVERY X

XX

X

x_

N1-

0

I I I I7.40 7.50

BLOOD pH

FIG. 6.

7.60 7.70

PLASMA

INORGANIC

PHOSPHORUS

hiM/L

2.00

1.75

I.50

1.25

1.00

.75

.50

.25

7.30J7.80

PLASMA

I NORGANIC

PHOSPHORUS

mM/L

2.00

1.75

1.50

1.25

1.00

.75

.50

.25

07.30

i7.80

144

x

I I I


TABLE IV

Urinary excretions in acute metabolic alkalosis

Control period Experimental period Recovery period

Determination Subjects Specimen 1 Specimen 2 Specimen 1 Specimen 2 Specimen 1 Specimen 2

Endogenous 01 153 146 190 154 116 126creatinine 05 186 172 157 156 151 136chromagen 07 138 149 141 140 142 149clearance, 11 107 126 146 133 132ml/min 13 130 141 138 120

Mean for specimen 146 145 155 144 132 137Mean for period 145 150 134SD for period 24 16 13

Phosphorus 01 18.2 17.2 24.1 17.4 18.9 18.5excretion, 05 11.4 10.0 10.5 9.4 15.8 18.6limoles/min 07 12.7 13.3 17.5 14.0 17.0 21.0

11 7.0 15.6 20.0 25.6 27.413 18.8 23.3 24.8 16.4

Mean forspecimen 12.3 15.0 19.1 18.2 19.1 19.4Mean for period 13.8 18.6 19.2SD for period 4.0 5.9 3.7

pressed throughout the experiment despite a late respiratory alkalosis. During recovery the plasmarecovery of the depressed creatinine clearance. phosphorus returned to 1.03 with only mild cor-Potassium excretion peaked with the onset of al- rection of the alkalosis. Plasma calcium and po-kalosis but gradually fell as blood levels fell. tassium fell significantly during alkalosis and

Metabolic alkalosis. Table III gives the ana- remained low during recovery.lyzed and derived data from the blood in six ex- Table IV and Figure 2 record the renal excre-periments during metabolic alkalosis produced by tion data with metabolic alkalosis. In spite ofNaHCO3 infusion. The broken lines of Figure 1 the falling plasma phosphorus concentration,represent the changes that were observed in there is a rise that is not significant in urinaryplasma and blood. A slightly less marked degree phosphorus excretion from a mean of 13.8 toof alkalosis was induced with a rise of mean pH 18.6 umoles per minute during the infusion and tofrom 7.41 to 7.59. The whole blood CO2 con- 19.2 ,tmoles per minute during recovery. Thetent rose from a mean of 20.3 to 31.8 mmoles per phosphorus clearance followed the same pattern,L. The calculated Pco2 rose from a mean of rising from a mean of 13.1 to 22.1 and 19.7 ml39 to 44 mm Hg. In contrast to the respiratory per minute. The creatinine clearance did notalkalosis experiments, during the recovery period change significantly during the period of alkalosisthere was only moderate reversion of the alkalosis or after, but a mean increase from 145 to 150toward the control level, with a fall in pH from ml per minute was noted. Urinary potassium ex-the mean of 7.59 during infusion to 7.53 in "re- cretion rose from a mean of 55 /AEq per minutecovery." Whole blood CO2 content and calcu- to 265 juEq per minute during infusion and re-lated Pco2 changed insignificantly during this mained elevated at 151 1uEq per minute duringperiod. recovery.The plasma inorganic phosphorus concentration Discussion

shows a consistent fall from a mean of 1.10 to 0.82mmole per L. This change was uniform in direc- The "normal" serum phosphorus concentrationtion but of smaller magnitude than that seen in is known to be affected by several determinants.

FIG. 6. RELATION BETWEEN PH AND PLASMA INORGANIC PHOSPHORUS DURING ACUTE

RESPIRATORY AND METABOLIC ALKALOSIS. Each plasma phosphorus level is plotted against asimultaneous blood pH. The solid line connects the last control value and the first experimentalvalue at 60 minutes. The dotted line connects the last experimental value and the first re-covery value 60 minutes later. Other points represent values during the established state.

145


TABLE V

Range of values of normal serum P

Mean 4SD Range Range Author

mg/loo ml mg/100 ml mmoles/L2.4-5.0 .78-1.62 (1 1)

2.44t.7 2.04.8* .65-1.55* (12)3-4 (adults) 1.0 -1.3 (14)5-6 (child) 1.6 -1.9 (14)2.4-4.2 .78-1.36 (15)

3.9 4.5 2.9-4.9 (adults)* .94-1.87* (17)4.3-6.0 1.39-1.94 (18)2.6-4.3* .84-1.39* (21)

3.2 i.5 2.7-3.7 .87-1.20 (34)2.5-4.5 .81-1.45 (37)

3.4 2.8-3.9 .90-1.26 (38)

* Mean ±t 2 SD.

Dietary phosphorus intake (20), stage of growth(14, 34), and time of day (35, 36) contribute tothe variability of the fasting serum phosphorusconcentration. Table V gives the range of normalvalues reported by several authors.The present data show that in normal man,

physiological and experimental disturbances ofacid-base balance can modify the serum phos-phorus concentration in a predictable manner.The inclusion of patients with unsuspected dis-turbances of acid-base balance in normal seriesincreases the apparent range of normal variationand impairs the sensitivity of the serum phos-phorus concentration in the diagnosis of disease.The relationship between plasma phosphorus

concentration and pH is shown in Figure 6.Control values are closely grouped in both ex-periments, but a large scatter is seen in the re-covery periods of both groups. Inspection ofTables I and III reveals a progressive rise inplasma phosphorus concentration without a cor-responding change in pH at the end of recovery,suggesting a rebound phenomenon. Figure 7represents mean values for all subjects for eachspecimen and shows the sequence of changes ob-served.Two important differences between respiratory

and metabolic alkalosis might account for the dif-ference in fall of phosphorus concentration. Theelevated total CO2 in metabolic alkalosis is inmarked contrast to its depression in respiratoryalkalosis. If phosphorus disappears by an ionexchange process, an elevated bicarbonate mightcompete with phosphorus for sites of exchangeand minimize the fall in phosphorus concentra-

tion in metabolic alkalosis. This competition forbinding sites has been described in vitro in bonesalts (39).The other difference between the two alkaloses

is in the rate of change of hydrogen ion concen-tration in the intracellular compartment. As hasbeen pointed out by Robin (40) acute changes inrespiratory acid-base relationships are trans-mitted into the cell much more rapidly than meta-bolic acid-base changes. If the fall in plasmaphosphorus concentration described here is at-tributable to intracellular migration of the ele-ment, a more rapid disappearance from the plasmamight be expected from the greater intracellularalkalosis of hyperventilation.The site of disappearance of phosphorus from

the extracellular fluid is a matter of major inter-

1.25-

PLASMA

INORGANIC

METABOLIC ALKALOSIS

1.oo

PHOSPHORUS ol

mnM/L

7.40 7.50

BLOOD pH

PLASMA

INORGANIC

PHOSPHORUS .5C

mM/L .25

7.60 7.70

RESPIRATORY ALKALOSIS

CONTROL 0

EXPERIMENTAL 0

RECOVERY X

7.40 7.50 7.60 7.70

BLOOD pH

FIG. 7. RELATION BETWEEN MEAN PH AND PLASMAINORGANIC PHOSPHORUS DURING ACUTE ALKALOSIS. ThepH and plasma phosphorus values for all blood specimensdrawn at identical experimental times were averaged andthe means plotted against each other. The solid linerepresents the temporal sequence of the specimens.

146

.7S

I .25+

.001-


est. The amount that must be accounted for canbe estimated at a maximum of 0.75 mmole per Lin 17 L of extracellular fluid or 12.7 mmoles.

Rapoport and associates (4) suggested that thefall in phosphorus concentration with short termhyperventilation might be due to changes in car-bohydrate metabolism. Haldane and Wiggles-worth (41) showed in 1920 that with hyper-ventilation the glucose tolerance curve becomesdiabetic in type. This impairment of glucose utili-zation should cause a rise in serum phosphorusrather than a fall. In the studies reported here,there is no evidence of the fall in blood glucosethat is seen when rapid deposition of glycogenlowers the serum phosphorus after insulin ad-ministration or secretion (42, 43).The fall in plasma inorganic phosphorus is not

accounted for by movement into the erythrocytesunless there is a rapid conversion to organic phos-phates. The inorganic phosphorus of whole bloodchanges in the same direction as plasma phos-phorus. This indicates that phosphorus has mi-grated out of the vascular compartment or hasbecome organically bound. A slow conversionto organic phosphates under conditions of in vitroglycolysis at low CO2 tensions has been described(44), but in the absence of accelerated glycolysisthis phenomenon is unlikely to proceed at the rateseen in the acute experiments.The renal excretion data clearly show that ex-

ternal losses of phosphorus do not account for thefall in plasma phosphorus concentration. Inrespiratory alkalosis the excretion falls nearly tozero. In metabolic alkalosis the phosphorus ex-cretion rises by an average of 5 /imoles per minute,but this rate for 90 minutes would produce anincrease over control of only 0.45 mmole ofphosphorus. This is insufficient to account forthe phosphorus lost from the extracellular fluid.The distinctly greater creatinine clearances asso-ciated with bicarbonate infusion may well accountfor the greater phosphorus excretion in metabolicalkalosis.The possibility that alkalosis produces the pre-

cipitation of some salt of phosphate needs to beconsidered (45). The molar changes in calciumconcentration in plasma are consistently muchsmaller than the changes in phosphorus concen-tration with alkalosis. Since in bone salts the

molar ratio Ca: P is in the range 1.3 to 2.0 (45),it is unlikely that precipitation of calcium phos-phate accounts for the fall in serum phosphorus.Corresponding changes in magnesium concentra-tion have not been studied in these experiments.With respiratory alkalosis, a rise in serum ci-

trate from 1.80 to 2.77 mg per 100 ml (.094 to.145 mmole per L) and a rise in serum lactatefrom 8.3 to 16.3 mg per 100 ml (.92 to 1.82mmoles per L) have been reported by Axelrod(7). The fall in serum phosphorus reported atthe same time was from 3.51 to 2.61 mg per 100ml (1.13 to 0.84 mmole per L). If citrate isassumed to have a valence of - 3 and lactate avalence of - 1, and if 80%o of the phosphorushas a valence of - 2 and the rest of - 1, a crudecalculation of equivalence may be made. In theplasma 1.05 mEq per L of organic acids have ap-peared, and 0.54 mEq per L of phosphorus havebeen lost. This calculation makes no correctionfor activity of the components exchanged, but theorder of magnitude is such that an ion exchangemechanism seems possible. Similar data for meta-bolic alkalosis are not available. Preliminarystudies of a-v differences across cortical bone andparenchymal organs in the dog suggest that ex-change for lactate in the soft tissues rather thanexchange in bone is the site of disappearance ofphosphorus in alkalosis.

Summary

Acute respiratory and metabolic alkalosis havebeen shown to depress plasma phosphorus con-centration in normal man. The fall in plasmaphosphorus concentration is greater in respiratorythan in comparable levels of extracellular meta-bolic alkalosis. This fall is not attributable to in-creased renal excretion or to migration into redblood cells. The evaluation of low serum phos-phorus concentrations should always be carriedout with a knowledge of the pH and total CO2content of the plasma.

Appendix

The standard deviation of the mean of a pair of dupli-cates was considered to be the index of precision and isdesignated SD. When duplicate determinations differedby more than 2 to 4 SD, depending upon their absolutevalues, a new sample was analyzed, and the pair of

147


values closest togetifor the various typelowing table.

Determination

Blood pHBlood CO2 con-

tent

Plasma inorganicphosphorus

Blood inorganicphosphorus

Urine inorganicphosphorus

Plasma calcium

Plasma potassiumUrine potassiumHematocrit

Blood glucosePlasma creatininechromogen

Urine creatininechromogen

1. Haldane, J. B.Woodrow. Tman inorganic96, 1.

2. Giebisch, G., L.trarenal respcof respiratory

3. Brassfield, C. R.tion of the p]fected by charJ. Physiol. 19

4. Rapoport, S., C.ris, and M. L(breathing on 1

blood in man.

5. Brown, E. B., JGollan, A. IElectrolyte chtilation in mar

6. Stanbury, S. W.,sponse to res

ll, 357.7. Axelrod, D. R.

perventilation.8. Okel, B. B., an

ventilation inand subjective108, 757.

9. Barker, E. S., R.Clark. The i

perimental reE

clin. Invest.

her was utilized. Statistical indexes 10. Bartter, F. C. The parathyroids. Ann. Rev. Physiol.es of analyses are shown in the fol- 1954, 16, 429.

11. Chambers, E. L., Jr., G. S. Gordan, L. Goldman, andE. C. Reifenstein, Jr. Tests for hyperparathyroid-

Units Range SD ism: tubular reabsorption of phosphate, phosphate7.38-7.72 .005 deprivation, and calcium infusion. J. clin. Endocr.

1956, 16, 1507.mmoles/L 13.6-22.2 .24 12. Bogdonoff, M. D., A. H. Woods, J. E. White, and

F. L. Engel. Hyperparathyroidism. Amer. J.mmoles/L .18-1.65 .016 Med. 1956, 21, 583.

13. Nordin, B. E. C., and R. Fraser. The Indirect As-mmoles/L .39-1.67 .050 sessment of Parathyroid Function. Ciba Founda-

tion Symposium on Bone Structure and Metabo-mmoles/L 1.2-116.2 .50 lism. Boston, Little, Brown, 1956, p. 222.mmoles/L 2.03-2.70 .03 14. Copp, D. H. Calcium and phosphorus metabolism.mEq/L 3.00-4.90 .11 Amer. J. Med. 1957, 22, 275.mEq/L 1.8-80.0 .74 15. Talpers, S. J., and J. D. Stein, Jr. Tubular reab-vol/100 ml 39.7-56.4 .2 sorption of phosphorus as a measure of para-mg/100 ml 110-202 1.1 thyroid activity. Metabolism 1959, 8, 170.

16. Kyle, L. H., M. Shaaf, and J. J. Canary. Phosphatemg/100 ml .72-1.34 .02 clearance in the diagnosis of parathyroid dys-

function. Amer. J. Med. 1958, 24, 240.mg/ml .062-1.187 .065 17. Reynolds, T. B., H. Lanman, and N. Tupikova.

Reevaluation of phosphate excretion tests in theReferences diagnosis of hyperparathyroidism. Arch. intern.

Med. 1960, 106, 48.S., V. B. Wigglesworth, and C. E- 18. Fraser, D. Clinical manifestations of genetic aber-he effect of reaction changes on hu- rations of calcium and phosphorus metabolism.:metabolism. Proc. roy. Soc. B 1924, J. Amer. med. Ass. 1961, 176, 281.

19. Beisel, W. R., E. S. Gerard, K. G. Barry, E. G.Berger, and R. F. Pitts. The ex- Herndon, Jr., W. H. Meroney, and L. H. Kyle.

rnse to acute acid-base disturbances Phosphate abnormalities in hyperparathyroidism.origin. J. clin. Invest. 1955, 34, 231. Metabolism 1961, 10, 771.

., and V. G. Behrmann. A correla- 20. Pronove, P., and F. C. Bartter. Diagnosis of hyper-H of arterial blood and urine as af- parathyroidism. Metabolism 1961, 10, 349.iges in pulmonary ventilation. Amer. 21. Keating, F. R., Jr. Diagnosis of primary hyper-41, 132, 272. parathyroidism. J. Amer. med. Ass. 1961, 178,D. Stevens, G. L. Engel, E. B. Fer- 547.ogan. The effect of voluntary over- 22. Rasmussen, H. Parathyroid hormone. Nature andthe electrolyte equilibrium of arterial mechanism of action. Amer. J. Med. 1961, 30, 112.J. biol. Chem. 1946, 163, 411. 23. Shock, N. W., and A. B. Hastings. Studies of the

[r., G. S. Campbell, J. 0. Elam, F. acid-base balance of the blood; 1. A microtech-Hemingway, and M. B. Visscher. nique for the determination of the acid-base bal-anges with chronic passive hyperven- ance of the blood. J. biol. Chem. 1934, 104, 565.i. J. appl. Physiol. 1949, 1, 848. 24. Singer, R. B., J. Shohl, and D. B. Bluemle. Simul-and A. E. Thomson. The renal re- taneous determination of pH, CO. content, and

piratory alkalosis. Clin. Sci. 1952, cell volume on 0.1 ml aliquots of cutaneous blood.Clin. Chem. 1955, 1, 287.

Organic acids and calcium in hy- 25. Peters, J. P., and D. D. Van Slyke. QuantitativeJ. appl. Physiol. 1961, 16, 709. Clinical Chemistry. Vol. II. Methods. Baltimore,

d J. W. Hurst. Prolonged hyper- Williams & Wilkins, 1932, p. 283.man. Associated electrolyte changes 26. Singer, R. B., and A. B. Hastings. An improvedsymptoms. Arch. intern. Med. 1961, clinical method for the estimation of disturbances

of the acid-base balance of human blood. MedicineB. Singer, J. R. Elkinton, and J. K. (Baltimore) 1948, 27, 223.

renal response in man to acute ex- 27. Fiske, C. H., and Y. Subbarow. The colorimetricspiratory alkalosis and acidosis. J. determination of phosphorus. J. biol. Chem. 1925,957, 36, 515. 66, 375.

148


28. Folin, O., and H. Wu. A system of blood analysis.J. biol. Chem. 1919, 38, 81.

29. Bonsnes, R. W., and H. H. Taussky. On the colori-metric determination of creatinine by the Jaffe re-

action. J. biol. Chem. 1945, 158, 581.30. Fales, F. W. A micromethod for the determination

of serum calcium. J. biol. Chem. 1953, 204, 577.31. Nelson, N. A photometric adaptation of the So-

mogyi method for the determination of glucose.J. biol. Chem. 1944, 153, 375.

32. Snedecor, G. W. Statistical Methods Applied toExperiments in Agriculture and Biology. Ames,Iowa, The Iowa State College Press, 5th ed., 1956,p. 291.

33. Ibid., p. 246.34. Albright, F., and E. C. Reifenstein, Jr. The Para-

thyroid Glands and Metabolic Bone Disease. Bal-timore, Williams and Wilkins, 1948, p. 4.

35. Ollayos, R. W., and A. W. Winkler. Urinary ex-

cretion and serum concentration of inorganic phos-phate in man. J. clin. Invest. 1943, 22, 147.

36. Stanbury, S. W., and A. E. Thomson. Diurnal vari-ations in electrolyte excretion. Clin. Sci. 1951,10, 267.

37. Sackner, M. A., A. P. Spivack, and L. J. Balian.Hypocalcemia in the presence of osteoblasticmetastases. New Engl. J. Med. 1960, 262, 173.

38. Henneman, P. H., P. H. Benedict, A. P. Forbes, andH. R. Dudley. Idiopathic hypercalcuria. NewEngl. J. Med. 1958, 259, 802.

39. Neuman, W. F., T. Y. Toribara, and B. J. Mulryan.The surface chemistry of bone. IX. Carbonate:phosphate exchange. J. Amer. chem. Soc. 1956, 78,4263.

40. Robin, E. D. Of men and mitochondria-intracel-lular and subcellular acid-base relations. NewEngl. J. Med. 1961, 265, 780.

41. Haldane, J. B. S., V. B. Wigglesworth, and C. E.Woodrow. The effect of reaction changes on hu-man carbohydrate and oxygen metabolism. Proc.roy. Soc. B 1924, 96, 15.

42. Wigglesworth, V. B., C. E. Woodrow, W. Smith,and L. B. Winter. On the effect of insulin onblood phosphate. J. Physiol. (Lond.) 1923, 57,447.

43. Harrop, G. A., Jr., and E. M. Benedict. The par-ticipation of inorganic substances in carbohydratemetabolism. J. biol. Chem. 1924, 59, 683.

44. Tulin, M., T. S. Danowski, P. M. Hald, and J. P.Peters. The distribution and movements of in-organic phosphate between cells and serum ofhuman blood. Amer. J. Physiol. 1947, 149, 678.

45. Neuman, W. F., and M. W. Neuman. The ChemicalDynamics of Bone Mineral. Chicago, Universityof Chicago Press, 1958, p. 41.

149

effects of alkalosis on plasma concentration excretion of

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