3. A six year old child is hospitalized with severe diarrhea and vomiting.

Examination of the child showed

severe dehydration and tachypnea. The laboratory investigations performed are as follows:

ABG: pH 7.12, PCO2: 15 mmHg, PO2: 82 mmHg, HCO3: 4 mEq/l

Serum chemistry Na 140 mEq/L, K: 4 mEq/L, Cl 115 mEq/L, Creatinine: 1.29 mEq/L. Serum albumin 2.8
mEq/l.

Random urine Na 10 mEq/L, K 10 mEq/L, Cl 50 mEq/L

Calculate the following and provide an interpretation

a. Degree of Compensation
pCO2 = 1.5 x HCO3 + 8 2
= 1.5 x 4 + 8 2
= 14 2 = 12 to 16
Recorded PCO2 being 15, there is complete respiratory compensation

b. Anion Gap
= Na - (Cl+HCO3)
= 140 (115 + 4) = 21 hence HAGMA
Adjusted with albumin of 2.8 ( for every drop 1gram drop of albumin there is drop of AG by 2.5
to 3 mmol/l), hence actual AG for 1 gram drop of albumin in current scenario should be about
24.

c. Delta ratio: Formula for AG is (Observed AG Normal AG )/ (Observed HCO3 Normal HCO3)
= (24 12) / ( 24 4) = 12/20 = 0.6
Since <1, there is both component of NAGMA + HAGMA

The ratio gives one of four results:

1. < 0.4 due to a pure NAGMA

2. 0.4 - 0.8 due to a mixed NAGMA + HAGMA
3. 0.8 - 2.0 due to a pure HAGMA
4. >2.0 due to a mixed HAGMA + metabolic
alkalosis (or pre-existing compensated respiratory acidosis)

d. Urine anion gap

UAG: UNA + UK UCL = 10 + 10 50 = - 30
 Hence Urine anion gap is negative, thus indicating that the contributory parameters for mixed
anion gap is due to diarrhea and not renal cause.i.e., RTA

A positive urine anion gap suggests a low urinary NH4+ (e.g. renal tubular acidosis).
A negative urine anion gap suggests a high urinary NH4+ (e.g. diarrhea).

Generate the final diagnosis based on the interpretation

Hence there is mixed NAGMA + HAGMA, with complete respiratory compensation, with pre-renal AKI
attributed to diarrhea.