Medicine:High anion gap metabolic acidosis
| High anion gap metabolic acidosis | |
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| Other names | we can to measure the anion gap by measure the Na , Cl and bicarbonate (Hco3-) in the serum then , we do some math AG= Na-cl-Hco3 . the normal range of anion gap is 10-12 . above 12 called high anion gap |
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High anion gap metabolic acidosis is a form of metabolic acidosis characterized by a high anion gap (a medical value based on the concentrations of ions in a patient's serum). Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. Several types of metabolic acidosis occur, grouped by their influence on the anion gap. The anion gap can be increased due to relatively low levels of cations other than sodium and potassium (e.g. calcium or magnesium). An anion gap is usually considered to be high if it is over 12 mEq/L.
High anion gap metabolic acidosis is typically caused by acid produced by the body. More rarely, it may be caused by ingesting methanol or overdosing on aspirin.[1][2] The Delta Ratio is a formula that can be used to assess elevated anion gap metabolic acidosis and to evaluate whether mixed acid base disorder (metabolic acidosis) is present. The list of agents that cause high anion gap metabolic acidosis is similar to but broader than the list of agents that cause a serum osmolal gap.
Causes
The most common causes of high anion gap metabolic acidosis are: ketoacidosis, lactic acidosis, kidney failure (also known as renal failure), and toxic ingestions.[3]
Ketoacidosis can occur as a complication of type I diabetes mellitus (diabetic ketoacidosis), but can occur due to other disorders, such as chronic alcoholism and undernutrition. In these conditions, excessive free fatty acid metabolism results in the production of ketoacids, acetoacetic acid, and beta-hydroxybutyrate.
Lactic acidosis results from excess formation and decreased metabolism of lactate, which occurs during states of anaerobic metabolism. It is the most common cause of metabolic acidosis in hospitalized patients. The most serious form occurs during various states of shock, due to episodes of decreased liver perfusion.
Kidney failure results in decreased acid excretion and increased bicarbonate excretion.
Toxins that result in acidic metabolites may trigger lactic acidosis. Rhabdomyolysis, a muscle-wasting disease, is a rare cause of metabolic acidosis.
Mnemonics
Various mnemonics are used to assist clinicians in the detection and diagnosis of conditions that may result in high anion gap metabolic acidosis:
The newer 2008 mnemonic "GOLD MARK" was proposed in The Lancet reflecting current causes of anion gap metabolic acidosis:[4]
- G — glycols (ethylene glycol & propylene glycol)
- O — oxoproline, a metabolite of paracetamol / acetaminophen
- L — L-lactate, the chemical responsible for lactic acidosis
- D — D-lactate
- M — methanol
- A — aspirin
- R — renal failure
- K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis
The mnemonic MUDPILES is commonly used to remember the causes of increased anion gap metabolic acidosis.[5][6]
- M — Methanol
- U — Uremia (chronic kidney failure)
- D — Diabetic ketoacidosis
- P — Paracetamol, Propylene glycol (used as an inactive stabilizer in many medications; historically, the "P" also stood for Paraldehyde, though this substance is not commonly used today)
- I — Infection, Iron, Isoniazid (which can cause lactic acidosis in overdose), Inborn errors of metabolism (an especially important consideration in pediatric patients)[7]
- L — Lactic acidosis
- E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.)
- S — Salicylates
Another frequently used mnemonic is KARMEL.
- K — Ketoacidosis
- A — aspirin
- R — Renal failure
- M — Methanol
- E — Ethylene glycol
- L — Lactic acidosis
Another frequently used mnemonic is KULT.[8] ACEGIFTS is a mnemonic for the toxins.
- K — Ketoacidosis (DKA, Alcoholic ketoacidosis)
- U — Uremia
- L — Lactic acidosis
- T — Toxins (Ethylene glycol, methanol, as well as drugs, such as aspirin, Metformin)
The preferred mnemonic of D. Robert Dufour, the chief of the Pathology and Laboratory Medicine Service, Veterans Affairs Medical Center at Washington DC, is DUMPSALE, which omits the I of MUDPILES as the proposed values of *I* are exceedingly rare in clinical practice.[citation needed]
- D — Diabetic ketoacidosis
- U — Uremia
- M — Methanol
- P — Paraldehyde
- S — Salicylates
- A — Alcoholic ketoacidosis
- L — Lactic acidosis
- E — Ethylene Glycol
The mnemonic for toxins is ACE GIFTs: Aspirin, Cyanide, Ethanolic ketosis, Glycols (ethylene and propylene), Isoniazid, Ferrous iron, [[Toluene], salicylates]. Most of these cause a lactic acidosis.[citation needed]
Other
Diagnosis
Management
See also
- Normal anion gap acidosis
References
- ↑ "Anion Gap (Blood)". University of Rochester Medical Center. http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=167&ContentID=anion_gap_blood.
- ↑ Sabatini, S.; Kurtzman, N. A. (2008). "Bicarbonate Therapy in Severe Metabolic Acidosis". Journal of the American Society of Nephrology 20 (4): 692–5. doi:10.1681/asn.2007121329. PMID 18322160.
- ↑ "Metabolic Acidosis - Endocrine and Metabolic Disorders". https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/acid-base-regulation-and-disorders/metabolic-acidosis.
- ↑ Mehta, Ankit N; Emmett, Joshua B; Emmett, Michael (2008). "GOLD MARK: An anion gap mnemonic for the 21st century". The Lancet 372 (9642): 892. doi:10.1016/S0140-6736(08)61398-7. PMID 18790311.
- ↑ MedicalMnemonics.com: 1203 3255
- ↑ "Anion Gap: Acid Base Tutorial, University of Connecticut Health Center". http://fitsweb.uchc.edu/student/selectives/TimurGraham/Anion_Gap.html.
- ↑ Carmody, J Bryan; Norwood, Victoria F (2012). "A clinical approach to paediatric acid–base disorders". Postgraduate Medical Journal 88 (1037): 143–51. doi:10.1136/postgradmedj-2011-130191. PMID 22267531.
- ↑ "Metabolic Acidosis, Stepwise Approach to ABGs: Acid Base Tutorial, University of Connecticut Health Center". http://fitsweb.uchc.edu/student/selectives/TimurGraham/Stepwise_approach.html.
- ↑ Chang, Chin-Tung; Chen, Yung-Chang; Fang, Ji-Tseng; Huang, Chiu-Ching (2009). "High Anion Gap Metabolic Acidosis in Suicide: Don't Forget Metformin Intoxication—Two Patients' Experiences". Renal Failure 24 (5): 671–5. doi:10.1081/JDI-120013973. PMID 12380915.
- ↑ "Metabolic Acidosis: Acid-Base Regulation and Disorders: Merck Manual Professional". http://www.merck.com/mmpe/sec12/ch157/ch157c.html#sec12-ch157-ch157c-1030.
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