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Clinical Approach To A Patient With An Acid-Base Disturbance
Clinical Approach To A Patient With An Acid-Base Disturbance
Clinical Presentation which is 1.35 in this case. A delta ratio between 1 and 2
suggests that the patient may not have an additional acid-
A 65-year-old woman with a medical history of dia-
base disorder. However, this equation assumes that all
betes mellitus, obesity, compensated cirrhosis, and
buffering is extracellular and by bicarbonate, neither of
nonalcoholic steatohepatitis had right first distal phalanx
which is correct. The calculated PaCO2 by Winter’s for-
osteomyelitis diagnosed 4 weeks before presentation
mula, that is, PaCO2 = (1.5 × [HCO3−] + 8) ± 2, is
and underwent right below-knee amputation. She was
23 mm Hg, which is slightly above the arterial blood
admitted to the hospital with abdominal pain and
gas–measured PaCO2 of 19 mm Hg, indicating that the
hematemesis.
patient also has a respiratory alkalosis. In summary, our
On admission, the patient denied chest pain, short-
patient has a high-AG metabolic acidosis with mild res-
ness of breath, nausea, vomiting, diarrhea, or urinary
piratory alkalosis.
symptoms. She also denied using over-the-counter
medications. Home medications included aspirin,
81 mg, daily; furosemide, 20 mg, daily; insulin glar- What is the differential diagnosis for this
gine, 10 units, daily; levofloxacin, 500 mg, daily; and patient’s acid-base disturbance?
linezolid, 600 mg, twice a day. The causes of high-AG metabolic acidosis are listed in
On physical examination, the patient’s body tem- Box 1.
perature was 36.5 C (97.7 F), heart rate was 86
beats/min, blood pressure was 105/53 mm Hg, Table 1. Patient’s Initial Basic Laboratory Values
respiration rate was 14 breaths/min, and oxygen satu- Reference
ration was 98% while breathing room air. Cardiopul- Test Result Range
monary examination findings were unremarkable. Her Hemoglobin, g/dL 6.9 12-16
abdomen was distended with mild epigastric tenderness White blood cell count, /μL 2,500 3,700-11,000
to palpation. There was no lower extremity edema. Platelet count, ×103/μL 24 150-400
Neurologic examination was positive for asterixis. Sodium, mmol/L 131 132-148
Table 1 outlines the patient’s initial laboratory studies. Potassium, mmol/L 5.5 3.5-5
Urinalysis results were benign and blood cultures were Chloride, mmol/L 94 98-111
negative. Computed tomography of the abdomen Bicarbonate, mmol/L 10 23-32
demonstrated moderate ascites and suggested liver Serum urea nitrogen, mg/dL 29 10-25
cirrhosis. Chest x-ray revealed no acute cardiopulmo- Creatinine, mg/dL 0.69 0.7-1.4
nary process. Calcium, mg/dL 7.9 8.4-10.5
Albumin, g/dL 2.3 3.5-5.0
Glucose, mg/dL 170 65-100
• What is the acid-base disturbance in this case? Alanine aminotransferase, U/L 7 0-45
Aspartate aminotransferase, U/L 16 7-40
• What is the differential diagnosis for this acid- Alkaline phosphatase, U/L 256 40-150
base disturbance? Bilirubin, total, mg/dL 0.3 0-1.5
PTT, s 50 22-32
• What is the most likely cause of this patient’s INR 1.2
acid-base disturbance? LDH, U/L 125 0-249
Lactate, mmol/L 11.5 0.4-1.9
• What is the best treatment for this patient’s β-Hydroxybutyrate, mg/dL 0.3 0-3
QUIZ
• Ketoacidosis
Trujillo, MD, and Mohamad Hanouneh, MD.
> Diabetic ketoacidosis
Authors’ Affiliations: Division of Nephrology, Department of
> Alcoholic ketoacidosis
Medicine, Johns Hopkins University School of Medicine (CEC,
> Starvation ketoacidosis
SM, JMMT, MH); and Nephrology Center of Maryland,
• Lactic acidosis (D-lactate or L-lactate) Baltimore, MD (MH).
• Ingestion
Address for Correspondence: Carmen Elena Cervantes, MD,
> Intoxication with glycols
1830 E Monument St, Rm 416, Baltimore, MD 21287. E-mail:
> Methanol
ccervan2@jhmi.edu
> Salicylates
Support: None.
• Kidney failure
Financial Disclosure: The authors declare that they have no
Based on information in Gabow.1
relevant financial interests.
Quiz
Peer Review: Received April 19, 2020. Direct editorial input from 3. Singh R, Arain E, Buth A, Kado J, Soubani A, Imran N.
the Education Editor and a Deputy Editor. Accepted in revised Ethelene glycol poisoning: an unusual cause of altered
form June 27, 2020. mental status and the lessons learned from management of
Publication Information: © 2020 Published by Elsevier Inc. on the disease in the acute setting. Case Rep Crit Care.
behalf of the National Kidney Foundation, Inc. doi: 10.1053/ 2016;2016:9157393.
j.ajkd.2020.06.022 4. LiverTox: Clinical and research information on drug-
induced liver injury. National Institute of Diabetes
and Digestive and Kidney Diseases; 2012. Accessed
References June 27, 2020. https://www.ncbi.nlm.nih.gov/books/
1. Gabow PA. Disorders associated with an altered anion gap. NBK547852/.
Kidney Int. 1985;27(2):472-483. 5. Kraleti S, Soultanova I. Pancytopenia and lactic acidosis
2. Madias NE. Lactic acidosis. Kidney Int. 1986;29(3):752- associated with linezolid use in a patient with empyema.
774. J Ark Med Soc. 2013;110(4):62-63.
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