Metabolic acidosis

Non-anion gap metabolic acidosis (Hyperchloremic/normal anion gap metabolic acidosis)

O Bicarbonate loss
4 Renal
Proximal RTA (type II) (hypokalemic or normokalemic)
Carbonic anhydrase inhibitors
Therapy of diabetic ketoacidosis
4 GI
Diarrhea (hypokalemic)
!ancreatic drainage
&reteral diversion
O Acid gain
4 Hyperalimentation fluids
4 mmonium chloride ingestion
O Impaired acid excretion
4 Renal failure (mild to moderate, as long is GFR is above 20% of normal)
4 Classic distal RTA (type I) (hypokalemic, calcium phosphate stones, nephrocalcinosis)
4 Hyperkalemic distal RT (type IV)

Anion gap metabolic acidosis: when there is an anion gap, there is something that is accounting for the deviation
O M ethanol (anion gap + osmolal gap)
O U remia
O D iabetic ketoacidosis (anion gap + osmolal gap)
O P araldehyde
O I NH
O L actic acidosis
O E thylene glycol (anion gap + osmolal gap + calcium oxalate crystals)
O S alycylates* salycylate toxicity causes anion gap acidosis with respiratory alkalosis, dont cause osmolal gap

High anion gap metabolic acidosis usually does not occur in renal failure until GFR declines below 20% of normal. As
GFR falls, there is an increase in anion gap due to retetion of unmeasured anions such as sulfate, phosphate, etc

Urine anion gap: distinguish between non-renal (diarrhea) and renal origin (RTA) of non-anion gap acidosis
O UAG = U
Na
+ U
K
- U
Cl

O In the setting of acidemia, urinary ammonium production should be stimulated and the & should be < 0
O
O UAG < 0 Diarrhea (non-renal cause)
4 Is kidney functioning normally? If so it should be producing NH4 to remove acid in an acidotic state
4 If NH4 production is high, urine chloride will be high because chloride is excreted with
ammonium as a balanced pair (principle of electroneutrality)
4 If urine chloride is high, urine anion gap will be negative
O UAG > 0 RTA
4 If the kidney is unable to produce ammonium, urine chloride will be low and &G will be positive


Metabolic acidosis: compensation (are the lungs functioning correctly?)
Winter's formula: pCO2 = 1.5 x [HCO
3
] + 8 + 2


Metabolic Alkalosis: Differential
Saline responsive
ECFV depletion (NG suction, diuretics, chronic diarrhea, laxative abuse) Why are these alkalosis not acidosis?
***distinguishing between vomiting and diarrhea and laxatives
See question number 8 (slide 37)
O Vomiting: hypochloremia
O iuretics: hyperchloremic
O axative: metabolic acidosis (GI bicarbonate loss)

Saline resistant
Severe K depletion, Primary hyperaldosteronism, Cushing's syndrome, Ectopic ACTH, Bartter's, Gittleman's

Osmolal gap = measured osmolality - calculated osmolality
Normal gap < 10mOsm/kg
n osmol gap > 10 indicates the presence of an unmeasured osmole contributing to plasma tonicity
Osmolal gap is important because there are many ingestions that can be fatal.

Causes of increased osmolal gap
O Things associated with metabolic acidosis that will also raise osmolal gap
4 Methanol
4 thylene glycol
4 lcoholic ketoacidosis
4 iabetic ketoacidosis
O Things not associated with acidosis that will raise osmolal gap
4 thanol
4 Isopropyl alcohol
4 Glycine
4 Mannitol

A measured [HCO
3
] much higher than predicted by the increase in anion gap is a clue that a "hidden"
metabolic alkalosis may also be present

A measured [HCO
3
] much less than predicted by the increase in anion gap is a clue that a "hidden" normal
anion gap metabolic acidosis may also be present.