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Problem-Based Review: a Patient with Metabolic Acidosis

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Problem-Based Review: a Patient with Metabolic Acidosis Acute Medicine 2012 11(4): 251-256 251 Trainee Section Problem-Based Review: A patient 251 with metabolic acidosis saf R Allan & C Foster Abstract Metabolic acidosis is a common metabolic derangement present in the acute medical patient. A thorough and structured investigative approach is required as there are many causes and management is reliant on identifying these. In particular calculation of the anion gap with correction for albumin level and use of the delta ratio can be helpful in complex cases especially in patients where a combination of metabolic derangements may be present. Keywords metabolic acidosis, anion gap, delta ratio, renal tubular acidosis, bicarbonate Key points • Calculation of the anion gap is crucial in identifying the cause of metabolic acidosis. • Metabolic acidosis is often multi-factorial and the delta ratio calculation can be useful in identifying situations where a normal gap acidosis coexists with a raised anion gap cause. • Identification of the specific cause(s) of metabolic acidosis is vital as this will usually guide treatment. • Bicarbonate treatment has a role in some cases but adverse effects should be considered. Case Vignette Although the anion gap calculation will narrow A 37 year old male with no past medical history presents our differential (Table 2), many possible explanations to the acute medical unit (AMU) with a history of general for the acidosis remain, especially when the gap is deterioration in health over the last 8 months. He has lost 10 high. The mnemonic MUDPILERS (Methanol, kg of weight and has severe fatigue. More recently he describes a Uraemia, Diabetic Ketoacidosis or other causes Table 1. arterial blood gas of patient in case vignette Table 2. Causes of Metabolic Acidosis according to Anion Gap1,2,3,4,5 pH 7.2 Raised anion gap Normal anion gap pCO 2.6kPa 2 - Renal failure HCO3 loss HCO3 8mmol/l Ketoacidosis GI – diarrhoea, ileus, pO 15kPa (on room air) 2 (DKA,sarvation,alcohol) pancreato- or uretero fistula feeling of breathlessness. A blood gas is performed (see Table 1). Paraldyhyde, Toluene, Type 2 – Renal Tubular Iron,Tricyclics, Isoniazid Acidosis (RTA) What are the potential causes of this acidosis and how can these be further classified? Ethylene Glycol, Ethanol, Acetazolamide Methanol The low bicarbonate and low carbon dioxide is consistent with a metabolic acidosis with an attempt Lactate (type A or B), D Addition of chloride at respiratory compensation. The differential for lactate (short bowel) (e.g. 0.9% saline use) Russell Allan ST5 Acute Medicine, a diagnosis that explains this finding remains large Rhabdomyolysis Failure to secrete H+ Western Infirmary, but can be narrowed significantly by calculating the Type 1 RTA Glasgow anion gap using the following equation: Email: russellallan@doctors. Type 4 RTA org.uk + + - - Type 3 RTA Anion gap (AG) = (Na + K ) – (HCO3 + Cl ) Hypoaldosteronism Christopher Foster [Normal range – 10-20 (on old colorimetry (1o/2o), Consultant Acute Medicine, Royal Alexandra Hospital, measurements); 3-11 (on modern ion-selection electrode Tubulo-interstital renal Paisley. measurements)] disease Email: cjfoster@doctors. org.uk © 2012 Rila Publications Ltd. 252 Acute Medicine 2012; 11(4): 251-256 Problem-Based Review: A patient with metabolic acidosis of ketoacidosis, Paraldyhyde, Iron/Isoniazid, expressed by the delta gap and delta ratio, calculated Lactate, Ethylene glycol/Ethanol, Rhabdomyolysis, using the following formulae: Salicylate) may be helpful. What else can influence the anion gap? Delta gap (ΔAG) = (Calculated AG – 12) – The anion gap can also be expressed as: (24 – measured HCO3) Delta ratio = (Calculated AG – 12) / (24 – Unmeasured anions – Unmeasured cations measured HCO3) This demonstrates how an anion gap can be high The delta ratio should be approximately balanced if or low in the absence of an acidosis. The major a pure raised anion gap (AG) acidosis exists (ratio of anion that can act in this way is albumin. A low or between 1-2) high anion gap will result, depending on whether A delta gap > 6 (or ratio > 2) suggests a concurrent the albumin level is lower or higher than normal, metabolic alkalosis (or chronic respiratory acidosis), respectively. When calculating an anion gap we A delta gap < -6 (or ratio <1) suggests there is also can adjust for an abnormal albumin by using the a concurrent normal AG metabolic acidosis4,5 following equation:6 His corrected anion gap is calculated at 20 and the cause Corrected anion gap = 0.25 x (40 – albumin (g/l)) of this elevation is found to be due to ketones identified in + anion gap (AG) his urine. His blood glucose is elevated at 28mmol/l and as a result, a diagnosis of type 1 diabetes is made with a Any other ion not represented in the AG equation first presentation of DKA. His delta ratio is calculated at can influence the gap but this is usually to a lesser 0.5 suggesting the co-existing presence of a normal anion degree than that seen with albumin. As well as gap acidosis. The treating physicians are aware that there the anion, phosphate, and cations, magnesium is a potential connection between diabetes and renal tubular and calcium, we must consider the presence of acidosis and plan to explore this possibility. other charged particles not present in normal What is meant by the term renal tubular acidosis circumstances. Paraproteins seen in myeloma and (RTA)? other gammopathies can be positively or negatively RTAs by definition are a group of disorders with charged and lithium has a positive charge resulting dysfunction of renal tubule acidification mechanisms in a low AG when taken in excess. Rarely the AG but well preserved glomerular filtration rate. Table 3 can even become negative, a phenomenon that is describes the RTA types and the differential causes most likely to be seen with lab errors – for example, for a normal anion gap acidosis,highlighting any chloride level can be over-estimated in the presence differences which will aid diagnosis. of bromide containing drugs, hyperlipidaemia or In type 2 RTA, it is the proximal tubule HCO – salicylate poisoning. 3 reabsorption that malfunctions. Clearly this results in - How will we know if there is more than one disorder a high loss of HCO3 in the urine. However, distal present? tubular reabsorption does still occur, resulting in a – When a raised AG cause is found we should continue serum acidosis with a [HCO3 ] that rarely falls below – to explore for other metabolic derangements. This 12. When the serum [HCO3 ] falls it means less is will involve testing for other anions that may have filtered and, as a result, less is present in the tubular accompanied an acid (e.g. lactate, ketones etc.) and lumen. For this reason, the high urinary pH and high – also calculating the delta ratio. [HCO3 ] in the urine may not be obvious until the – serum [HCO3 ] is normalised. In fact, the urine pH What is the Delta ratio and how can it be calculated? can be <5.3 when an equilibrium has been established. It should be appreciated that where the AG is The proximal tubular reabsorption defect may not – increased, the degree of change from a normal gap be unique to HCO3 and often is accompanied by reflects the quantity of non-chloride anion added. that of glucose, phosphate, urate, potassium and This anion will have an accompanying H+, each of others. The obvious treatment for this should be to which will be buffered by a bicarbonate ion. It follows replace the deficit using high doses of bicarbonate. that the change in the anion gap (ΔAG) from that The correction of the acidosis can be problematic as - individual’s normal and the change in the HCO3 it will cause the already hypokalaemic state to worsen - concentration (ΔHCO3 ) from that individual’s further. Potassium must therefore always be replaced normal should be approximately the same. Where along with alkalinization therapy. In adults, the most the ΔAG is significantly less than the measured common cause of type 2 RTA is myeloma and this - 6 ΔHCO3 , a coexistent normal AG acidosis should should therefore always be considered . be considered. Where the ΔAG is significantly more In type 1 RTA, the deficient mechanism is at - + than the measured ΔHCO3 , the coexisting presence the terminal tubule involving the excretion of H . – of a metabolic alkalosis may be present. This can be In comparison to type 2 RTA, the serum [HCO3 ] © 2012 Rila Publications Ltd. Acute Medicine 2012; 11(4): 251-256 253 Problem-Based Review: A patient with metabolic acidosis Table 3.1,7Classification and causes of Renal Tubular Acidosis Type 1 RTA Type 2 RTA GI HCO3 loss Tubulo- RTA T4 interstital disease Mechanism Defect exists at Defect exists Gastrointestinal In renal Aldosterone the distal tubule in the proximal loss of failure, failure resistance/ + preventing H tubule preventing bicarbonate ions to filter deficiency - secretion. reabsorption of HCO3 sulphuric acid (+/-glucose, amino is the main acids,phosphate,K+etc) mechanism for acidosis (high AG). When glomerulus intact but tubules affected only H+ secretion fails (i.e. normal AG) Causes Autoimmune Usually Myeloma in Gastroenteritis, Multiple Hypoadrenalism disease (esp. adults IBD, causes (1oor2oto Sjögrens (Fanconi syndrome in Ureteric or hyporeninaemia), syndrome), children) pancreatic fistula, CKD (esp. Renal transplant, Endocrinecasues Diabetic obstructive nephropathy), uropathy, Sickle Congenital cell disease, resistance cirrhosis Serum [K+] Low and Low and worsens as Low Often low High improves as acidosis is corrected acidosis does (can be high) Serum Very low ~12-20 Mild decrease Mild decrease [HCO3] (Often <10) only (usually > 17) Urinary pH Always > 5.5. Often < 5.5. Increases to < 5.3 Variable < 5.5 Can’t acidify >7.5 when bicarbonate urine infused Associations Nephrocalcinosis, Rickets/ osteomalacia Features of calcium stones cause Renal Usually normal Usually normal Can be Often Normal unless function deranged if also deranged cause is hypovolaemic CKD causing aldosterone resistance can fall significantly and be less than 10.
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