High anion gap metabolic acidosis

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When acidosis is present on blood tests, the first step in determining the cause is determining the anion gap. If the anion gap is high (>12 mEq/L), there are several potential causes.

High anion gap metabolic acidosis
Cat mudpiles - causes of high anion-gap metabolic acidosis.svg
Classification and external resources
Specialty endocrinology
ICD-10 E87.2
ICD-9-CM 276.2
DiseasesDB 15112

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). An anion gap is usually considered to be high if it is over 12 mEq/L.

High anion gap metabolic acidosis is caused generally by acid produced by the body,. More rarely, high anion gap metabolic acidosis 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 include:

The newest mnemonic was proposed in The Lancet reflecting current causes of anion gap metabolic acidosis:[3]

The mnemonic MUDPILES is commonly used to remember the causes of increased anion gap metabolic acidosis.[4][5]

Another frequently used mnemonic is KARMEL.

Another frequently used mnemonic is KULT.[7]

  • K — Ketoacidosis (DKA, AKA)
  • 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, 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 the [rare, in comparison] toxins is ACE GIFTs: Aspirin, Cyanide, Ethanolic ketosis, Glycols [ ethylene and propylene ], Isoniazid, Ferrous iron, Toluene. Most of these cause a lactic acidosis.[citation needed]




See also[edit]


  1. ^ "Anion Gap (Blood)". University of Rochester Medical Center. Retrieved 2014-02-18. 
  2. ^ 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. 
  3. ^ 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. 
  4. ^ MedicalMnemonics.com: 1203 3255
  5. ^ Anion Gap: Acid Base Tutorial, University of Connecticut Health Center
  6. ^ 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. 
  7. ^ "Metabolic Acidosis, Stepwise Approach to ABGs: Acid Base Tutorial, University of Connecticut Health Center". fitsweb.uchc.edu. Retrieved 2017-04-18. 
  8. ^ 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. 
  9. ^ "Metabolic Acidosis: Acid-Base Regulation and Disorders: Merck Manual Professional". Retrieved 2008-12-04.