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The most common causes of high anion gap metabolic acidosis are: ketoacidosis, lactic acidosis, kidney failure, and toxic ingestions. [3]Ketoacidosis can occur as a complication of diabetes mellitus (diabetic ketoacidosis), but can occur due to other disorders, such as chronic alcoholism and malnutrition.
The magnitude of this difference (i.e., "gap") in the serum is calculated to identify metabolic acidosis. If the gap is greater than normal, then high anion gap metabolic acidosis is diagnosed. The term "anion gap" usually implies "serum anion gap", but the urine anion gap is also a clinically useful measure. [4] [5] [6] [7]
Metabolic acidosis is a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance.Metabolic acidosis has three main root causes: increased acid production, loss of bicarbonate, and a reduced ability of the kidneys to excrete excess acids. [5]
Hyperchloremic acidosis is a form of metabolic acidosis associated with a normal anion gap, a decrease in plasma bicarbonate concentration, and an increase in plasma chloride concentration [1] (see anion gap for a fuller explanation).
The serum anion gap is useful for determining whether a base deficit is caused by addition of acid or loss of bicarbonate. Base deficit with elevated anion gap indicates addition of acid (e.g., ketoacidosis). Base deficit with normal anion gap indicates loss of bicarbonate (e.g., diarrhea).
Hyperparathyroidism – can cause hyperchloremia and increase renal bicarbonate loss, which may result in a normal anion gap metabolic acidosis. Patients with hyperparathyroidism may have a lower than normal pH, slightly decreased PaCO2 due to respiratory compensation, a decreased bicarbonate level, and a normal anion gap.
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Determining the cause of a metabolic acidosis that lacks a serum anion gap often depends on determining whether the kidney is appropriately excreting acid. The urine anion gap is an 'artificial' and calculated measure that is representative of the unmeasured ions in urine.