Anion Gap PY = (Na+ + K+) (Cl- + HCO3-) anion gap = the concentration of all the unmeasure anions in the

e plasma the normal anion gap epen s on serum phosphate an serum al!umin an ele"ate anion gap strongl# suggests a meta!olic aci osis normal $% to $& ' 3( then meta!olic aci osis in"aria!l# present %(-%) then $*3 +ill not ha"e a meta!olic aci osis

The effect of albumin & phosphate - the normal anion gap epen s on serum phosphate an serum al!umin - the normal ,- = (.% / 0al!umin1 (g*2) + $.3 / 0phosphate1 (mmol*2) - al!umin is the ma4or unmeasure anion an contri!utes almost the +hole of the "alue of the anion gap. - e"er# one gram ecrease in al!umin +ill ecrease anion gap !# %.3 to 3 mmoles. - a normall# high anion gap aci osis in a patient +ith h#poal!uminaemia ma# appear as a normal anion gap aci osis. - this is particularl# rele"ant in 5C6 patients +here lo+er al!umin le"els are common. Anion Gap Metabolic Acidosis accumulation of organic acids or impaired H+ excretion 2actate 7o/ins Ketones 8enal - this meta!olic aci osis is normall# manage !# al!umin -' if al!umin ecrease !# $g then ecrease anion gap !# %-3 points. - la! tests to or er = lactate9 glucose9 creatinine an urea9 urinar# :etones9 serum le"els of methanol9 ethanol9 paracetamol9 salic#lates an eth#lene gl#col. Non-anion Gap Metabolic Acidosis loss of HC !- from "C# Chlori e ,ceta;olami e*, isons -5 causes iarrhea*"omiting9 fistulae (pancreatic9 ureters9 !illar#9 small !o+el9 ileostom#) </tra 87, ($) - calculating urinar# anion gap helps to ifferentiate !et+een a -5 an renal cause of a normal anion gap aci osis (urinar# anion gap = Na+ + K+ - Cl-) -' the remaining significant unmeasure ions are NH=+ an HCO3- renal causes increase urinar# HCO3- e/cretion thus increase urinar# ,- -5 causes increase NH=+ e/cretion thus ecrease urinar# ,-

Jeremy Fernando (2010)

Causes of a $o% Anion Gap >ecrease in unmeasure anions (al!umin9 ilution) 5ncrease in unmeasure cations (multim#eloma9 h#percalcaemia9 h#permagnesaemia9 lithium O>9 !romi e O>9 pol#mi/in ?) Non ran om anal#tical errors (increase Na+9 increase "iscosit#9 io i e ingestion9 increase lipi s)

Jeremy Fernando (2010)