The Stewart approach--one clinician's perspective

Peter Stewart added controversy to an already troubled subject when he entered the clinical acid-base arena. His approach puts water dissociation at the centre of the acid-base status of body fluids. It is based on six simultaneous equations, incorporating the Laws of Mass Action, Mass Conservation, and Electrical Neutrality. Together with Gibbs-Donnan equilibria, these equations explain the diagnostically important PaCO(2)/pH relationship, and improve understanding of the physiologic basis of traditional acid-base approaches. Spin-offs have included new scanning tools for unmeasured ions, in particular the 'strong ion gap' and 'net unmeasured ions'. The most controversial feature is the designation of pH and bicarbonate concentrations as dependent variables, answerable exclusively to three independent variables. These are the strong ion difference (SID), the total concentration of non-volatile weak acid (A(TOT)), and PCO(2). Aspects of this assertion conflict with traditional renal physiology, and with current models of membrane H(+)/base transporters, oxidative phosphorylation, and proton and bicarbonate ionophores. The debate in this area is ongoing. Meanwhile, Stewart-style diagnostic and decision support systems such as the 'Strong Ion Calculator' and the web-site www.acidbase.org are now appearing.