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Anion gap
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Current events The anion gap is used to aid in the differential Pathophysiology sample values
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diagnosis of metabolic acidosis.
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Although the term "anion gap" usually implies "serum
Na + =140 Cl − =100 BUN =20 /
anion gap", the urine anion gap is also a clinically useful
Interaction Glu =150
measure. [1][2][3]
K + =4 CO 2 =22 PCr=1.0 \
Help
Contents [hide] ARTERIAL BLOOD GAS:
About Wikipedia
Community portal 1 Calculation HCO3 -=24 p a CO 2 =40 p a O 2 =95 pH=7.40
Recent changes 1.1 With potassium
ALVEOLAR GAS:
Contact Wikipedia 1.2 Without potassium (Daily practice)
p A CO 2 =36 p A O 2 =105 A -a g =10
2 Uses
OTHER:
3 Normal value ranges
Toolbox
4 Interpretation and causes Ca=9.5 Mg 2+ =2.0 PO 4 =1
What links here 4.1 High anion gap CK=55 BE =−0.36 AG =16
Related changes 4.2 Normal anion gap
SERUM OSMOLARITY/RENAL :
Upload file 4.3 Low anion gap
PMO = 300 PCO=295 POG =5 BUN:Cr=20
Special pages
5 References
Permanent link URINALYSIS :
6 External links
Cite this page UNa + =80 UCl− =100 UAG=5 FENa =0.95

UK + =25 USG=1.01 UCr=60 UO=800

Calculation [edit]
Print/export PROTEIN/GI/LIVER FUNCTION TESTS:
The concentrations are expressed in units of
Create a book LDH =100 TP=7.6 AST=25 TBIL =0.7
milliequivalents/liter (mEq/L) or in millimoles/litre
Download as PDF ALP =71 Alb =4.0 ALT=40 BC=0.5
(mmol/L).
Printable version
AST/ALT=0.6 BU=0.2

With potassium [edit] AF alb =3.0 SAAG =1.0 SOG =60

Languages
It is calculated by subtracting the serum concentrations CSF:
of chloride and bicarbonate (anions) from the CSF alb =30 CSF glu =60 CSF/S alb =7.5 CSF/S glu =0.4
Deutsch concentrations of sodium plus potassium (cations):
日本語 = ( [Na + ]+[K + ] ) − ( [Cl− ]+[HCO3 − ] )
Polski
Without potassium (Daily practice) [edit]
However, the potassium is frequently ignored because potassium concentrations, being very low,
usually have little effect on the calculated gap. This leaves the following equation:

= ( [Na + ] ) − ( [Cl− ]+[HCO3 − ] )

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Uses [edit]

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Anion gap is an 'artificial' and calculated measure that is representative of the unmeasured ions in
plasma or serum (serum levels are used more often in clinical practice).

Commonly measured cations include sodium (Na+ ), Potassium (K+ ), Calcium (Ca2+ ) and Magnesium
(Mg 2+ ). Cations that are generally considered 'unmeasured' include a few normally occurring serum
proteins, and some pathological proteins (e.g., paraproteins found in multiple myeloma). Likewise,
commonly 'measured' anions include chloride (Cl− ), bicarbonate (HCO 3 − ) and phosphate (H2 PO4 − ),
while commonly 'unmeasured' anions include sulphates and a number of serum proteins.

By definition, only Na+ , Cl − and HCO3 − (+/- K) are used when calculating the anion gap.
In normal health there are more measurable cations compared to measurable anions in the serum;
therefore, the anion gap is usually positive. Because we know that plasma is electro-neutral we can
conclude that the anion gap calculation represents the concentration of unmeasured anions. The
anion gap varies in response to changes in the concentrations of the above-mentioned serum
components that contribute to the acid-base balance. Calculating the anion gap is clinically useful, as
it helps in the differential diagnosis of a number of disease states.

Normal value ranges [edit]

The average anion gap for healthy adults is 8-12 mEq/L. As typical in medicine, abnormal values are
defined as 2 standard deviations over or under the average level; hence, the upper limit of normal is
12 mEq/L. [4] In the past, methods for the measurement of the anion gap consisted of colorimetry for
[HCO 3 − ] and [Cl− ] as well as flame photometry for [Na + ] and [K + ]. Thus normal reference values
ranged from 8 to 16 mEq/L plasma when not including [K + ] and from 10 to 20 mEq/L plasma when
including [K + ]. Some specific sources use 15 [5] and 8–16 mEq/L. [6][7] Modern analyzers make use
of ion-selective electrodes which give a normal anion gap as <11 mEq/L. Therefore according to the
new classification system a high anion gap is anything above 11 mEq/L and a normal anion gap is
between 3–11 mEq/L. [8]
A reference range provided by the particular lab that performs the testing should be used to
determine if the anion gap is outside of the normal range. A certain proportion of normal individuals
may have values outside of the 'normal' range provided by any lab.

Interpretation and causes [edit]

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Anion gap can be classified as either high, normal or, in rare cases, low. Laboratory errors need to
be ruled out whenever anion gap calculations lead to results that do not fit the clinical picture.
Methods used to determine the concentrations of some of the ions used to calculate the anion gap
may be susceptible to very specific errors. For example, if the blood sample is not processed
immediately after it is collected, continued leukocyte cellular metabolism may result in an increase in
the HCO3 − concentration, and result in a corresponding mild reduction in the anion gap. In many
situations, alterations in renal function (even if mild, e.g., as that caused by dehydration in a patient
with diarrhea) may modify the anion gap that may be expected to arise in a particular pathological

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Anion gap - Wikipedia, the free encyclopedia

condition.

A high anion gap indicates that there is loss of HCO3 − without a concurrent increase in Cl − .
Electroneutrality is maintained by the elevated levels of anions like lactate, beta-hydroxybutyrate and
acetoacetate, PO4 − , and SO4 − . These anions are not part of the anion-gap calculation and therefore
a high anion gap results. Thus, the presence of a high anion gap should result in a search for
conditions that lead to an excess of these substances.

High anion gap [edit]

Main article: High anion gap metabolic acidosis

The anion gap is affected by changes in unmeasured ions. A high anion gap indicates acidosis. e.g.
In uncontrolled diabetes, there is an increase in ketoacids (i.e. an increase in unmeasured anions)
and a resulting increase in the anion gap. In these conditions, bicarbonate concentrations decrease,
in response to the need to buffer the increased presence of acids (as a result of the underlying
condition). The bicarbonate is consumed by the unmeasured anion (via its action as a buffer)
resulting in a high anion gap.
Lactic acidosis
Ketoacidosis
Diabetic ketoacidosis
Alcohol abuse
Toxins:
Ethylene glycol
Lactic acid
Uremia
Methanol
Propylene Glycol
Phenformin
Aspirin
Cyanide, coupled with elevated venous oxygenation
Iron
Isoniazid

Renal failure, causes high anion gap acidosis by decreased acid excretion and decreased HCO3 −
reabsorption. Accumulation of sulfates, phosphates, urate, and hippurate accounts for the high
anion gap.
Note: a useful mnemonic to remember this is MUDPILES (methanol, uremia, diabetic ketoacidosis,
propylene glycol, isoniazid, lactic acidosis, ethylene glycol, salicylates). A newer mnemonic CUTE
DIMPLES includes C for Cyanide and T for Toluene. Historically, the "P" in MUDPILES was for
paraldehyde. As paraldehyde is no longer used medically, the "P" in the MUDPILES mnemonic
currently refers to propylene glycol, a substance common in pharmaceutical injections such as
diazepam or lorazepam. Accumulation of propylene glycol is converted into lactate and pyruvate,
which causes lactic acidosis.

Normal anion gap [edit]

Main article: Normal anion gap acidosis

In patients with a normal anion gap the drop in HCO3 − is compensated for almost completely by an
increase in Cl − and hence is also known as hyperchloremic acidosis.

The HCO3 − lost is replaced by a chloride anion, and thus there is a normal anion gap.

Gastrointestinal loss of HCO3 − (i.e., diarrhea) (note: vomiting causes hypochloraemic alkalosis)

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Renal loss of HCO3 − (i.e. proximal renal tubular acidosis and joel intoxication(RTA) also known as
type 2 RTA)
Renal dysfunction (i.e. distal renal tubular acidosis also known as type 1 RTA)
Ingestions
Ammonium chloride and Acetazolamide, ifosfamide.
Hyperalimentation fluids (i.e. total parenteral nutrition)
Some cases of ketoacidosis, particularly during rehydration with Na+ containing IV solutions.
Alcohol (such as ethanol) can cause a high anion gap acidosis in some patients, but a mixed
picture in others due to concurrent metabolic alkalosis.
Mineralocorticoid deficiency (Addison's disease)
Note: a useful mnemonic to remember this is FUSEDCARS (fistula (pancreatic), uretogastric
conduits, saline administration, endocrine (hyperparathyroidism), diarrhea, carbonic anhydrase
inhibitors (acetazolamide), ammonium chloride, renal tubular acidosis, spironolactone)

Low anion gap [edit]

A low anion gap is frequently caused by hypoalbuminemia. Albumin is a negatively charged protein
and its loss from the serum results in the retention of other negatively charged ions such as chloride
and bicarbonate. As bicarbonate and chloride anions are used to calculate the anion gap, there is a
subsequent decrease in the gap.
In hypoalbuminaemia the anion gap is reduced from between 2.5 to 3 mmol/L per g/dL decrease in
serum albumin. [9] Common conditions that reduce serum albumin in the clinical setting are
hemorrhage, nephrotic syndrome, intestinal obstruction and liver cirrhosis.
The anion gap is sometimes reduced in multiple myeloma, where there is an increase in plasma IgG
(paraproteinaemia).[10]

Corrections can be made for hypoalbuminemia to give an accurate anion gap. [11]

References [edit]

1. ^ "Urine Anion Gap: Acid Base Tutorial,
University of Connecticut Health Center" .
Retrieved 2008-11-14.
2. ^ "Urine anion and osmolal gaps in metabolic
acidosis" . Retrieved 2008-11-14.
3. ^ Kirschbaum B, Sica D, Anderson FP (June
1999). "Urine electrolytes and the urine anion
and osmolar gaps". The Journal of Laboratory
and Clinical Medicine 133 (6): 597–604.
doi:10.1016/S0022-2143(99)90190-7 .
PMID 10360635 .
4. ^ Serum Anion Gap: Its Uses and Limitations in
Clinical Medicine
5. ^ Physiology at MCG 7/7ch12/7ch12p51
6. ^ "The Anion Gap" . Retrieved 2008-10-04.
7. ^ "Anion Gap: Acid Base Tutorial, University of
Connecticut Health Center" . Retrieved 2008-
10-04.
8. ^ Winter SD, Pearson JR, Gabow PA, Schultz
AL, Lepoff RB (February 1990). "The fall of the
serum anion gap". Archives of Internal
Medicine 150 (2): 311–3.
doi:10.1001/archinte.150.2.311 .
PMID 2302006 .
9. ^ Feldman M, Soni N, Dickson B (December
2005). "Influence of hypoalbuminemia or
hyperalbuminemia on the serum anion gap".
The Journal of Laboratory and Clinical
Medicine 146 (6): 317–20.
doi:10.1016/j.lab.2005.07.008 .
PMID 16310513 .
10. ^ Lolekha PH, Lolekha S (1 February 1983).
"Value of the anion gap in clinical diagnosis
and laboratory evaluation" . Clinical
Chemistry 29 (2): 279–83. PMID 6821931 .
11. ^ Figge J, Jabor A, Kazda A, Fencl V
(November 1998). "Anion gap and
hypoalbuminemia" . Critical Care Medicine
26 (11): 1807–10. PMID 9824071 .

External links [edit]

http://en.wikipedia.org/wiki/Anion_gap[3/2/2011 2:50:45 AM]

Anion gap - Wikipedia, the free encyclopedia

Clinical Physiology of Acid-Base and Electrolyte Disorders by Rose, Post

Intensive Care Medicine by Irwin and Rippe
The ICU Book by Marino
Calculator at mcw.edu
Metabolic acidosis by James L. Lewis, III, MD

v·d·e Urinary system, physiology: renal physiology and acid-base physiology

Filtration Renal blood flow · Ultrafiltration · Countercurrent exchange · Filtration fraction

Hormones affecting filtration Antidiuretic hormone (ADH) · Aldosterone · Atrial natriuretic peptide

Secretion/clearance Pharmacokinetics · Clearance of medications · Urine flow rate

Reabsorption Solvent drag · Na +  · Cl - · urea · glucose · oligopeptides · protein

Endocrine Renin · Erythropoietin (EPO) · Calcitriol (Active vitamin D) · Prostaglandins

Glomerular filtration rate · Creatinine clearance · Renal clearance ratio ·

Assessing Renal function/
Urea reduction ratio · Kt/V · Standardized Kt/V · Hemodialysis product ·
Measures of dialysis
PAH clearance (Effective renal plasma flow · Extraction ratio)

Fluid balance · Darrow Yannet diagram

Body water: Intracellular fluid/Cytosol · Extracellular fluid · (Interstitial fluid ·
Acid-base physiology Plasma · Transcellular fluid)

Base excess · Davenport diagram · Anion gap · Arterial blood gas ·

Winter's formula
Bicarbonate buffering system · Respiratory compensation ·
Buffering/compensation
Renal compensation
Fractional sodium excretion · BUN-to-creatinine ratio ·
Other
Tubuloglomerular feedback · Natriuresis · Urine

M: URI anat/phys/devp/cell noco/acba/cong/tumr, proc/itvp, drug (G4B), blte,

sysi/epon, urte urte

v·d·e Water-electrolyte imbalance and acid-base imbalance (E86–E87, 276)

Volume status Volume contraction (Dehydration/Hypovolemia)  · Hypervolemia

Na + Hypernatremia · Hyponatremia (Hypotonic, Isotonic)

Electrolyte K+ Hyperkalemia · Hypokalemia

Cl − Hyperchloremia · Hypochloremia

Metabolic: High anion gap (Ketoacidosis/Diabetic ketoacidosis, Lactic) ·

Acidosis Normal anion gap (Hyperchloremic, Renal tubular)
Respiratory
Acid-base
Metabolic: Contraction alkalosis
Alkalosis
Respiratory

Both Mixed disorder of acid-base balance

M: URI anat/phys/devp/cell noco/acba/cong/tumr, proc/itvp, drug (G4B), blte,

sysi/epon, urte urte

Categories: Acid-base disturbances | Electrolyte disturbances

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