Bicarbonate Reabsorption Research Articles

The serum 24,25-dihydroxyvitamin D concentration, a marker of vitamin D catabolism, is reduced in chronic kidney disease

Chronic kidney disease is characterized, in part, as a state of decreased production of 1,25-dihydroxyvitamin D (1,25(OH)2D); however, this paradigm overlooks the role of vitamin D catabolism. We developed a mass spectrometric assay to quantify serum concentration of 24,25-dihydroxyvitamin D (24,25(OH)2D), the first metabolic product of 25-hydroxyvitamin D (25(OH)D) by CYP24A1, and determined its clinical correlates and associated outcomes among 278 participants with chronic kidney disease in the Seattle Kidney Study. For eGFRs of 60 or more, 45–59, 30–44, 15–29, and under 15 ml/min/1.73m2, the mean serum 24,25(OH)2D concentrations significantly trended lower from 3.6, 3.2, 2.6, 2.6, to 1.7 ng/ml, respectively. Non-Hispanic Black race, diabetes, albuminuria, and lower serum bicarbonate were also independently and significantly associated with lower 24,25(OH)2D concentrations. The 24,25(OH)2D concentration was more strongly correlated with that of parathyroid hormone than was 25(OH)D or 1,25(OH)2D. A 24,25(OH)2D concentration below the median was associated with increased risk of mortality in unadjusted analysis, but this was attenuated with adjustment for potential confounding variables. Thus, chronic kidney disease is a state of stagnant vitamin D metabolism characterized by decreases in both 1,25(OH)2D production and vitamin D catabolism.

Type 3 renal tubular acidosis

Renal tubular acidosis (RTA) is a group of transport defects in the reabsorption of bicarbonate, the excretion of hydrogen ion (H+), or both, resulting in systemic acidosis and hypokalemia with a normal glomerular filtration rate. Although isolated proximal (type 2) or distal (type 1) tubular pathologies are well characterized, a combined pathology leading to type 3 RTA is very rare. Here, we report a case of type 3 RTA, using an algorithmic approach to classify a scenario of hypokalemic metabolic acidosis in the setting of episodic flaccid paralysis.

Targeted mutation of SLC4A5 induces arterial hypertension and renal metabolic acidosis

The human SLC4A5 gene has been identified as a hypertension susceptibility gene based on the association of single nucleotide polymorphisms with blood pressure (BP) levels and hypertension status. The biochemical basis of this association is unknown particularly since no single gene variant was linked to hypertension in humans. SLC4A5 (NBCe2, NBC4) is expressed in the collecting duct of the kidney and acts as an electrogenic ion-transporter that transports sodium and bicarbonate with a 1:2 or 1:3 stoichiometry allowing bicarbonate reabsorption with relatively minor concurrent sodium uptake. We have mutated the Slc4a5 gene in mice, which caused a persistent increase in systolic and diastolic BP. Slc4a5 mutant mice also displayed a compensated metabolic acidosis and hyporeninemic hypoaldosteronism. Analysis of kidney physiology revealed elevated fluid intake and urine excretion and increased glomerular filtration rate. Transcriptome analysis uncovers possible compensatory mechanisms induced by SLC4A5 mutation, including upregulation of SLC4A7 and pendrin as well as molecular mechanisms associated with hypertension. Induction of metabolic alkalosis eliminated the BP difference between wild-type and Slc4a5 mutant mice. We conclude that the impairment of the function of SLC4A5 favors development of a hypertensive state. We reason that the loss of sodium-sparing bicarbonate reabsorption by SLC4A5 initiates a regulatory cascade consisting of compensatory bicarbonate reabsorption via other sodium-bicarbonate transporters (e.g. SLC4A7) at the expense of an increased sodium uptake. This will ultimately raise BP and cause hypoaldosteronism, thus providing a mechanistic explanation for the linkage of the SLC4A5 locus to hypertension in humans.

Pathophysiology-Based Treatment of Idiopathic Calcium Kidney Stones

Idiopathic calcium oxalate (CaOx) stone-formers (ICSFs) differ from patients who make idiopathic calcium phosphate (CaP) stones (IPSFs). ICSFs, but not IPSFs, form their stones as overgrowths on interstitial apatite plaque; the amount of plaque covering papillary surface is positively correlated with urine calcium excretion and inversely with urine volume. The amount of plaque predicts the number of recurrent stones. The initial crystal overgrowth on plaque is CaP, although the stone is mainly composed of CaOx, meaning that lowering supersaturation (SS) for CaOx and CaP is important for CaOx stone prevention. IPSFs, unlike ICSFs, have apatite crystal deposits in inner medullary collecting ducts, which are associated with interstitial scarring. ICSFs and IPSFs have idiopathic hypercalciuria, which is due to decreased tubule calcium reabsorption, but sites of abnormal reabsorption may differ. Decreased reabsorption in proximal tubules (PTs) delivers more calcium to the thick ascending limb (TAL), where increased calcium reabsorption can load the interstitium, leading to plaque formation. The site of abnormal reabsorption in IPSFs may be the TAL, where an associated defect in bicarbonate reabsorption could produce the higher urine pH characteristic of IPSFs. Preventive treatment with fluid intake, protein and sodium restriction, and thiazide will be effective in ICSFs and IPSFs by decreasing urine calcium concentration and CaOx and CaP SS and may also decrease plaque formation by increased PT calcium reabsorption. Citrate may be detrimental for IPSFs if urine pH rises greatly, increasing CaP SS. Future trials should examine the question of appropriate treatment for IPSFs.

Inherited tubular renal acidosis

Renal tubular acidosis (RTA) is a tubulopathy characterized by metabolic acidosis with normal anion gap secondary to abnormalities of renal acidification. RTA can be classified into four main subtypes: distal RTA, proximal RTA, combined proximal and distal RTA, and hyperkalemic RTA. Distal RTA (type 1) is caused by the defect of H(+) secretion in the distal tubules and is characterized by the inability to acidify the urine below pH 5.5 during systemic acidemia. Proximal RTA (type 2) is caused by an impairment of bicarbonate reabsorption in the proximal tubules and characterized by a decreased renal bicarbonate threshold. Combined proximal and distal RTA (type 3) secondary to a reduction in tubular reclamation of bicarbonate and an inability to acidify the urine in the face of severe acidemia. Hyperkalemic RTA (type 4) may occur as a result of aldosterone deficiency or tubular insensitivity to aldosterone. Clinicians should be alert to the presence of RTA in patients with an unexplained normal anion gap acidosis, hypokalemia, recurrent nephrolithiasis and nephrocalcinosis. The mainstay of treatment of RTA remains alkali replacement.

Mechanisms mediating the diuretic and natriuretic actions of the incretin hormone glucagon-like peptide-1

Glucagon-like peptide-1 (GLP-1) is a gut incretin hormone considered a promising therapeutic agent for type 2 diabetes because it stimulates beta cell proliferation and insulin secretion in a glucose-dependent manner. Cumulative evidence supports a role for GLP-1 in modulating renal function; however, the mechanisms by which GLP-1 induces diuresis and natriuresis have not been completely established. This study aimed to define the cellular and molecular mechanisms mediating the renal effects of GLP-1. GLP-1 (1 μg·kg(-1)·min(-1)) was intravenously administered in rats for the period of 60 min. GLP-1-infused rats displayed increased urine flow, fractional excretion of sodium, potassium, and bicarbonate compared with those rats that received vehicle (1% BSA/saline). GLP-1-induced diuresis and natriuresis were also accompanied by increases in renal plasma flow and glomerular filtration rate. Real-time RT-PCR in microdissected rat nephron segments revealed that GLP-1 receptor-mRNA expression was restricted to glomerulus and proximal convoluted tubule. In rat renal proximal tubule, GLP-1 significantly reduced Na(+)/H(+) exchanger isoform 3 (NHE3)-mediated bicarbonate reabsorption via a protein kinase A (PKA)-dependent mechanism. Reduced proximal tubular bicarbonate flux rate was associated with a significant increase of NHE3 phosphorylation at the PKA consensus sites in microvillus membrane vesicles. Taken together, these data suggest that GLP-1 has diuretic and natriuretic effects that are mediated by changes in renal hemodynamics and by downregulation of NHE3 activity in the renal proximal tubule. Moreover, our findings support the view that GLP-1-based agents may have a potential therapeutic use not only as antidiabetic drugs but also in hypertension and other disorders of sodium retention.

The Sodium Bicarbonate Cotransporter (NBCe1) Is Essential for Normal Development of Mouse Dentition

Proximal renal tubular acidosis (pRTA) is a syndrome caused by abnormal proximal tubule reabsorption of bicarbonate resulting in metabolic acidosis. Patients with mutations to the SLC4A4 gene (coding for the sodium bicarbonate cotransporter NBCe1), have pRTA, growth delay, ocular defects, and enamel abnormalities. In an earlier report, we provided the first evidence that enamel cells, the ameloblasts, express NBCe1 in a polarized fashion, thereby contributing to trans-cellular bicarbonate transport. To determine whether NBCe1 plays a critical role in enamel development, we studied the expression of NBCe1 at various stages of enamel formation in wild-type mice and characterized the biophysical properties of enamel in NBCe1(-/-) animals. The enamel of NBCe1(-/-) animals was extremely hypomineralized and weak with an abnormal prismatic architecture. The expression profile of amelogenin, a known enamel-specific gene, was not altered in NBCe1(-/-) animals. Our results show for the first time that NBCe1 expression is required for the development of normal enamel. This study provides a mechanistic model to account for enamel abnormalities in certain patients with pRTA.

Posttranslational mechanisms associated with reduced NHE3 activity in adult vs. young prehypertensive SHR

Abnormalities in renal proximal tubular (PT) sodium transport play an important role in the pathophysiology of essential hypertension. The Na(+)/H(+) exchanger isoform 3 (NHE3) represents the major route for sodium entry across the apical membrane of renal PT cells. We therefore aimed to assess in vivo NHE3 transport activity and to define the molecular mechanisms underlying NHE3 regulation before and after development of hypertension in the spontaneously hypertensive rat (SHR). NHE3 function was measured as the rate of bicarbonate reabsorption by means of in vivo stationary microperfusion in PT from young prehypertensive SHR (Y-SHR; 5-wk-old), adult SHR (A-SHR; 14-wk-old), and age-matched Wistar Kyoto (WKY) rats. We found that NHE3-mediated PT bicarbonate reabsorption was reduced with age in the SHR (1.08 ± 0.10 vs. 0.41 ± 0.04 nmol/cm(2)×s), while it was increased in the transition from youth to adulthood in the WKY rat (0.59 ± 0.05 vs. 1.26 ± 0.11 nmol/cm(2)×s). Higher NHE3 activity in the Y-SHR compared with A-SHR was associated with a predominant microvilli confinement and a lower ratio of phosphorylated NHE3 at serine-552 to total NHE3 (P-NHE3/total). After development of hypertension, P-NHE3/total increased and NHE3 was retracted out of the microvillar microdomain along with the regulator dipeptidyl peptidase IV (DPPIV). Collectively, our data suggest that the PT is playing a role in adapting to the hypertension in the SHR. The molecular mechanisms of this adaptation possibly include an increase of P-NHE3/total and a redistribution of the NHE3-DPPIV complex from the body to the base of the PT microvilli, both predicted to decrease sodium reabsorption.

Separate Gating Mechanisms Mediate the Regulation of K2P Potassium Channel TASK-2 by Intra- and Extracellular pH

TASK-2 (KCNK5 or K(2P)5.1) is a background K(+) channel that is opened by extracellular alkalinization and plays a role in renal bicarbonate reabsorption and central chemoreception. Here, we demonstrate that in addition to its regulation by extracellular protons (pH(o)) TASK-2 is gated open by intracellular alkalinization. The following pieces of evidence suggest that the gating process controlled by intracellular pH (pH(i)) is independent from that under the command of pH(o). It was not possible to overcome closure by extracellular acidification by means of intracellular alkalinization. The mutant TASK-2-R224A that lacks sensitivity to pH(o) had normal pH(i)-dependent gating. Increasing extracellular K(+) concentration acid shifts pH(o) activity curve of TASK-2 yet did not affect pH(i) gating of TASK-2. pH(o) modulation of TASK-2 is voltage-dependent, whereas pH(i) gating was not altered by membrane potential. These results suggest that pH(o), which controls a selectivity filter external gate, and pH(i) act at different gating processes to open and close TASK-2 channels. We speculate that pH(i) regulates an inner gate. We demonstrate that neutralization of a lysine residue (Lys(245)) located at the C-terminal end of transmembrane domain 4 by mutation to alanine abolishes gating by pH(i). We postulate that this lysine acts as an intracellular pH sensor as its mutation to histidine acid-shifts the pH(i)-dependence curve of TASK-2 as expected from its lower pK(a). We conclude that intracellular pH, together with pH(o), is a critical determinant of TASK-2 activity and therefore of its physiological function.

Na+/H+ Exchanger NHE3 is differentially regulated in renal proximal tubules of pre‐hypertensive and hypertensive spontaneously hypertensive rats

The present work aimed to measure NHE3 in vivo transport activity and to define the mechanisms underlying NHE3 regulation in young pre‐hypertensive (5‐week‐old, systolic blood pressure (SBP) = 92 ± 2 mmHg) and adult hypertensive spontaneously hypertensive rats (SHR) (14‐week‐old, SBP = 187 ± 4 mmHg). NHE3 function was measured as the rate of bicarbonate reabsorption by means of in vivo microperfusion. NHE3‐mediated bicarbonate reabsorption was stimulated in 5‐week‐old SHR (44 ± 5%, P<0.01) and reduced in 14‐week‐old SHR (57 ± 4%, P<0.001) compared to Wistar Kyoto (WKY) rats at corresponding age. Stimulated NHE3 transport activity in young pre‐hypertensive SHR was associated with enhanced NHE3 microvillus expression, lower levels of phosphorylation at Ser552 and increased association with the enzyme dipeptidyl peptidase IV (DPPIV). Conversely, adult hypertensive SHR showed decreased NHE3 microvillus membrane content, higher relative ratio of phosphorylated Ser552, and lower amount of the NHE3‐DPPIV complex. No differences on renal cortical NHE3 protein content and mRNA levels were found between SHR and its WKY counterpart. We conclude that NHE3 is differentially regulated before and after development of hypertension in SHR by mechanisms that involve post‐translational modifications, subcellular redistribution and assembly with interacting proteins. Supported by FAPESP and CNPq

Study of Blood Porphyrin Spectral Profile for Diagnosis of Chronic Renal Failure

The progression to end-stage renal failure is independent of the initial pathogenic mechanism. Metabolic acidosis is a common consequence of chronic renal failure that results from inadequate ammonium excretion and decreased tubular bicarbonate reabsorption. Protoporphyrin IX (PpIX) is the immediate metabolic precursor of the heme molecule. The purpose of this study was to evaluate the levels of erythrocytes protoporphyrin IX at an animal model during progressive renal disease. A total of 36 eight-week-old male Wistar rats were divided into six groups: Normal, 4 and 8 weeks after 5/6 nephrectomy (NX). Renal function was evaluated by creatinine clearance and plasma creatinine levels. The autofluorescence of erythrocytes porphyrin of healthy and NX rats was analyzed using fluorescence spectroscopy. Emission spectra were obtained by exciting the samples at 405 nm. Significant differences between normal and NX rats autofluorescence shape occurred in the 600-700 nm spectral region. A correlation was observed between emission band intensity at 635 nm and progression of renal disease.

Determination of NABE in urine of high-yield dairy cows in early lactation in conditions of moderate heat stress

The work presents the results of investigations of the effect of moderate heat stress on the acidobasal status in high-yield dairy cows in early lactation. Improving performance in high-yield dairy cows increases their inclination toward metabolic disorders. The most likely to be affected is the acid-base balance, in particular when cows are exposed to heat stress. Investigations so far have shown that the taking of urine samples and their analysis is the best and fastest way to diagnose disorders in the acid-base balance. Investigations were carried out on 7 clinically healthy cows of the Holstein- Friesian breed in the phase of early lactation, 30 to 40 days (on days 30, 33 and 40 ) following calving during the summer period, during the month of July, when there were significant variations in daily and nightly temperatures. The cows were in the second and fourth lactation, the annual milk yield was 8000 L milk per cow. The average daily milk production in the early phase of lactation ranged from 35 to 40 L. The cows were fed mixed rations (TMR) twice daily. Lucerne hay in limited quantities was given to the cows prior to the mixed feed ration. The ration for this animal category was optimized on the grounds of the daily milk production. The balance of cations and anions in the feed ration stood at 95 mEq/kg DM. The results clearly demonstrate the cows' response to moderate heat stress through the defense parameters in urine (urine pH, NABE (net-acid-base-excretion), acids, bases, ammonium ion (NH4). The determination of the kidney NABE yields more correct data than the urine pH on acidotic conditions. The results of examinations of the urine pH do not show any digressions from physiological values and are approximately the same in all cows during the investigated periods. Normal NABE values are from 100-200 mmol/L. Burdening with acid products results in a NABE range from 0-100mmol/L, and metabolic acidosis results in NAB<0 mmol/L. NABE in the cows in this experiment revealed that the organism is burdened by acid metabolic products and it stood at 58.28?27.96 mmol/L on day 30, 69.28?29.89 mmol/L on day 33, and 60.60?26.88mmol/L on day 40. Consequently, it seems that NABE values are decreased in cases of acidosis due to stepped up H+ excretion and stepped up bicarbonate reabsorption.

Altered Renal Expression of Acid-base Transporters in Rats with Glycerol-induced Tubular Injury

＋− ＋ the kidney by semiquantitative immunoblotting and immunohistochemistry. In the experimental rats, creatinine clearance was decreased, whereas fractional sodium excretion was not changed. Urine pH and bicarbonate concentrations were decreased, although plasma pH and bicarbonate concentrations were not changed. In the experimental group, the protein expression of Na,K-ATPase α1-subunit was decreased in the cortex and outer stripe of outer medulla (cortex/OSOM) and inner stripe of outer medulla (ISOM) but increased in the inner medulla. The expression of NHE3 was decreased in the cortex/OSOM and ISOM, and that of NBC1 was decreased in the cortex/OSOM. By contrast, the expression of H ＋ -ATPase was increased in the cortex/OSOM and inner medulla but was unchanged in the ISOM. Immunohistochemical analyses confirmed the immunoblotting data. In glycerol-induced tubular injury, the downregulation of Na,K-ATPase α1-subunit, NHE3, and NBC1 may contribute to impaired tubular reabsorption of sodium and bicarbonate. The upregulation of H ＋ -ATPase may play a preventive role against the development of metabolic acidosis.

Index of Suspicion

Index of Suspicion

A 42-Year-Old Woman With Flaccid Paralysis

A 42-Year-Old Woman With Flaccid Paralysis

Effect of renoguanylin on hydrogen/bicarbonate ion transport in rat renal tubules

Renoguanylin (REN) is a recently described member of the guanylin family, which was first isolated from eels and is expressed in intestinal and specially kidney tissues. In the present work we evaluate the effects of REN on the mechanisms of hydrogen transport in rat renal tubules by the stationary microperfusion method. We evaluated the effect of 1 μM and 10 μM of renoguanylin (REN) on the reabsorption of bicarbonate in proximal and distal segments and found that there was a significant reduction in bicarbonate reabsorption. In proximal segments, REN promoted a significant effect at both 1 and 10 μM concentrations. Comparing control and REN concentration of 1 μM, JHCO 3 −, nmol cm − 2 s − 1 − 1,76 ± 0,11 control × 1,29 ± 0,08 REN 10 μM; P < 0.05, was obtained. In distal segments the effect of both concentrations of REN was also effective, being significant e.g. at a concentration of 1 μM (JHCO 3 −, nmol cm − 2 s − 1 − 0.80 ± 0.07 control × 0.60 ± 0.06 REN 1 μM; P < 0.05), although at a lower level than in the proximal tubule. Our results suggest that the action of REN on hydrogen transport involves the inhibition of Na +/H +exchanger and H +-ATPase in the luminal membrane of the perfused tubules by a PKG dependent pathway.

Low luminal pH aggravates fatty acid bound albumin induced O2·− production in renal proximal tubular cell

It is known that fatty acid bound albumin induces oxidative stress in proximal tubular cells. Although luminal pH of proximal tubule decreases according to the reabsorption of bicarbonate, it is not examined well how luminal pH affects the production of superoxide, O2·−. Therefore, we examined the role of luminal pH in the O2·− production.We applied oleic acid bound albumin(OA‐alb, 15g/L) to the HK‐2 cells, human proximal tubule cell line, and measured the production with dihydroethidium. The production was evaluated as the increasing rate of ethidium intensity under real time fluorescent microscopy. When buffer pH is above 6.6, the production was not significant(O2·− production; 0.15 ± 0.06 unit/sec at pH 6.9 and 0.34 ± 0.15 unit/sec at pH6.6, p=0.297). However, by decreasing buffer pH to 6.4, OA‐alb increased the production to 1.45 ± 0.28 unit/sec (p=0.026 versus pH 6.6). A Na/H exchanger inhibitor, dimethylamiloride blunted the production by 62%.In summary, the luminal acidic pH, which activates Na/H exchanger through the reduction of intracellular pH, aggravates OA‐alb induced O2·− production in proximal tubular cells.

Effects of extracellular nucleotides on renal tubular solute transport

A range of P2 receptor subtypes has been identified along the renal tubule, in both apical and basolateral membranes. Furthermore, it has been shown that nucleotides are released from renal tubular cells, and that ectonucleotidases are present in several nephron segments. These findings suggest an autocrine/paracrine role for nucleotides in regulating tubular function. The present review catalogues the known actions of extracellular nucleotides on tubular solute transport. In the proximal tubule, there is firm evidence that stimulation of apical P2Y(1) receptors inhibits bicarbonate reabsorption, whilst basolaterally applied ATP has the opposite effect. Clearance studies suggest that systemic diadenosine polyphosphates profoundly reduce proximal tubular fluid transport, through as yet unidentified P2 receptors. To date, only circumstantial evidence is available for an action of nucleotides on transport in the loop of Henle; and no studies have been made on native distal tubules, though observations in cell lines suggest an inhibitory effect on sodium, calcium and magnesium transport. The nephron segment most studied is the collecting duct. Apically applied nucleotides inhibit the activity of small-conductance K(+) channels in mouse collecting duct, apparently through stimulation of P2Y(2) receptors. There is also evidence, from cell lines and native tissue, that apically (and in some cases basolaterally) applied nucleotides inhibit sodium reabsorption. In mice pharmacological profiling implicates P2Y(2) receptors; but in rats, the receptor subtype(s) responsible is/are unclear. Recent patch-clamp studies in rat collecting ducts implicate apical P2Y and P2X subtypes, with evidence for both inhibitory and stimulatory effects. Despite considerable progress, clarification of the physiological role of the tubular P2 receptor system remains some way off.

Direct action of aldosterone on bicarbonate reabsorption in in vivo cortical proximal tubule

The direct action of aldosterone (10(-12) M) on net bicarbonate reabsorption (J(HCO(3)(-))) was evaluated by stationary microperfusion of an in vivo middle proximal tubule (S2) of rat kidney, using H ion-sensitive microelectrodes. Aldosterone in luminally perfused tubules caused a significant increase in J(HCO(3)(-)) from a mean control value of 2.84 +/- 0.08 [49/19 (n degrees of measurements/n degrees of tubules)] to 4.20 +/- 0.15 nmol.cm(-2).s(-1) (58/10). Aldosterone perfused into peritubular capillaries also increased J(HCO(3)(-)), compared with basal levels during intact capillary perfusion with blood. In addition, in isolated perfused tubules aldosterone causes a transient increase of cytosolic free calcium ([Ca(2+)](i)), monitored fluorometrically. In the presence of ethanol (in similar concentration used to prepare the hormonal solution), spironolactone (10(-6) M, a mineralocorticoid receptor antagonist), actinomycin D (10(-6) M, an inhibitor of gene transcription), or cycloheximide (40 mM, an inhibitor of protein synthesis), the J(HCO(3)(-)) and the [Ca(2+)](i) were not different from the control value; these drugs also did not prevent the stimulatory effect of aldosterone on J(HCO(3)(-)) and on [Ca(2+)](i). However, in the presence of RU 486 alone [10(-6) M, a classic glucocorticoid receptor (GR) antagonist], a significant decrease on J(HCO(3)(-)) and on [Ca(2+)](i) was observed; this antagonist also inhibited the stimulatory effect of aldosterone on J(HCO(3)(-)) and on [Ca(2+)](i). These studies indicate that luminal or peritubular aldosterone (10(-12) M) has a direct nongenomic stimulatory effect on J(HCO(3)(-)) and on [Ca(2+)](i) in proximal tubule and that probably GR participates in this process. The data also indicate that endogenous aldosterone stimulates J(HCO(3)(-)) in middle proximal tubule.

Calcium-Alkali Syndrome Due to Vitamin D Administration and Magnesium Oxide Administration

Calcium-Alkali Syndrome Due to Vitamin D Administration and Magnesium Oxide Administration