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Among the various causes of high anion gap metabolic acidosis, several involve oxidative pathways of alcohol metabolism through alcohol dehydrogenase. Substances such as methanol and ethylene glycol have limited intrinsic toxicity but are converted into more toxic substances (formic acid and oxalic acid respectively).
Elevated anion gap is concerning, because many causes of this are immediately life-threatening. (Unlike, for example, non-anion-gap metabolic acidosis – where most causes are not life threats). Bicarbonate <22 mM with a normal anion gap indicates a pure non-anion-gap metabolic acidosis (NAGMA).
Metabolic acidosis can develop if you have too many acids in your blood that wipe out bicarbonate (high anion gap metabolic acidosis) or if you lose too much bicarbonate in your blood as a result of kidney disease or kidney failure (normal anion gap metabolic acidosis).
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 most common causes of high anion gap metabolic acidosis (HAGMA) are listed in Table 1. They are arranged as the mnemonic “GOLDMARK” (Glycols [ethylene, propylene, and diethylene], 5-Oxoproline [acetaminophen], l-Lactic Acid, d-Lactic acid, Methanol, Aspirin, Renal failure, Ketoacidosis).
A high anion gap metabolic acidosis may be caused by lactate buildup (e.g., shock or overexercising), ketone buildup (e.g., fasting or type 1 diabetes complication), advanced kidney disease, and aspirin toxicity.
An elevated anion gap metabolic acidosis can be caused by salicylate toxicity, diabetic ketoacidosis, and uremia (MUDPILES). Non-Gap metabolic acidosis is due to GI loss of bicarbonate (diarrhea) or a failure of kidneys to excrete acid.
The most common causes of normal anion gap acidosis are. Gastrointestinal (GI) or renal HCO 3 − loss. Impaired renal acid excretion. Normal anion gap metabolic acidosis is also called hyperchloremic acidosis because the kidneys reabsorb chloride (Cl −) instead of reabsorbing HCO 3 −.
Acid-base disorders are pathologic changes in carbon dioxide partial pressure (Pco2) or serum bicarbonate (HCO3−) that typically produce abnormal arterial pH values. Acidemia is serum pH < 7.35. Alkalemia is serum pH > 7.45. Acidosis refers to physiologic processes that cause acid accumulation or alkali loss.
Physiologic interpretation of the serum anion gap; Causes of elevated anion gap metabolic acidosis; Causes of hyperchloremic (normal anion gap) metabolic acidosis; Combined elevated anion gap and hyperchloremic acidoses; OVERVIEW OF THERAPY. General approach and rationale - Acute metabolic acidosis - Chronic metabolic acidosis