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(See also 38) Multiple toxins and drugs can increase the anion gap by increasing endogenous acid production Examples include methanol (metabolized to formic acid), ethylene glycol (glycolic and oxalic acid), and salicylates (salicylic acid and lactic acid), which can cause a mixed disorder of metabolic acidosis with respiratory alkalosis In toluene poisoning, a metabolite hippurate is rapidly excreted by the kidney and may present as a normal anion gap acidosis Isopropyl alcohol, which is metabolized to acetone, increases the osmolar gap, but not the anion gap



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Multiline text (aka Word Wrap) · Issue #8 · MrRio/jsPDF · GitHub
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At GFRs below 20 mL/min, the inability to excrete H+ with retention of acid anions such as PO43 and SO42 results in an increased anion gap acidosis, which rarely is severe The unmeasured anions replace HCO3 (which is consumed as a buffer) Hyperchloremic normal anion gap acidosis develops in earlier stages of CKD

NORMAL ANION GAP ACIDOSIS (TABLE 21 15)

The hallmark of this disorder is that the low HCO3 of metabolic acidosis is associated with hyperchloremia, so that the anion gap remains normal The most common causes are gastrointestinal HCO3 loss and defects in renal acidification (renal tubular acidoses) The urinary anion gap can differentiate between these two common causes (see below)

R1 =





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Bicarbonate is secreted in multiple areas in the gastrointestinal tract Small bowel and pancreatic secretions contain large amounts of HCO3 Therefore, massive diarrhea or pancreatic drainage can result in HCO3 loss because of increased HCO3 secretion and decreased absorption Hyperchloremia occurs because the ileum and colon secrete HCO3 in a one-to-one exchange for Cl by countertransport The resultant volume contraction causes further increased Cl retention by the kidney in the setting of decreased anion, HCO3 Patients with ureterosigmoidostomies can develop hyperchloremic metabolic acidosis because the colon secretes HCO3 in the urine in exchange for Cl

This is a common disorder of chronically malnourished patients who consume large quantities of alcohol daily Most of these patients have mixed acid base disorders (10% have a triple acid base disorder) Although decreased HCO3 is usual, 50% of the patients may have normal or alkalemic pH Three types of metabolic acidosis are seen in alcoholic ketoacidosis: (1) Ketoacidosis is due to -hydroxybutyrate and acetoacetate excess (2) Lactic acidosis: Alcohol metabolism increases the NADH:NAD ratio, causing increased production and decreased utilization of lactate Accompanying thiamine defi-

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Distal H+ Secretion Serum [K+] Urinary NH4+ Plus Minimal Urine pH < 55 Titratable Acid Urinary Anion Gap Negative

Renal Defect Gastrointestinal HCO3 loss Renal tubular acidosis I Classic distal II Proximal secretion IV Hyporeninemic hypoaldosteronism Distal H+ secretion Proximal H+ Distal Na+ reabsorption, K+ secretion, and H+ secretion None

NaHCO3 (1 3 mEq/kg/d) NaHCO3 or KHCO3 (10 15 mEq/kg/d), thiazide Fludrocortisone (01 05 mg/ d), dietary K+ restriction, furosemide (40 160 mg/d), NaHCO3 (1 3 mEq/kg/d)

Modified and reproduced, with permission, from Cogan MG Fluid and Electrolytes: Physiology and Pathophysiology McGraw-Hill, 1991

7-2

B Renal Tubular Acidosis (RTA)

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