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Anion gap
From Wikipedia, the free encyclopedia
Cl = 100
BUN = 20
K+
CO2 = 22
PCr = 1.0
Glu = 150
=4
= 24 paCO2 = 40
paO2 = 95
pH = 7.40
ALVEOLAR GAS:
pACO2 = 36 pAO2 = 105
OTHER:
The term "anion gap" usually implies "serum anion gap", but
the urine anion gap is also a clinically useful measure.[3][4][5][6]
Ca = 9.5
Mg2+ = 2.0
PO4 = 1
CK = 55
BE = 0.36
AG = 16
A-a g = 10
SERUM OSMOLARITY/RENAL:
PMO = 300 PCO = 295
Contents
1 Calculation
1.1 With potassium
1.2 Without potassium (daily practice)
2 Uses
3 Normal value ranges
4 Interpretation and causes
4.1 High anion gap
4.2 Normal anion gap
4.3 Low anion gap
5 References
6 External links
POG = 5
BUN:Cr = 20
URINALYSIS:
UNa+ = 80
UCl = 100
UAG = 5
FENa = 0.95
UK+
USG = 1.01
UCr = 60
UO = 800
= 25
TP = 7.6
AST = 25
TBIL = 0.7
ALP = 71
Alb = 4.0
ALT = 40
BC = 0.5
SOG = 60
CSF:
CSF alb = 30 CSF glu = 60 CSF/S alb = 7.5 CSF/S glu = 0.4
Calculation
The concentrations are expressed in units of milliequivalents/liter (mEq/L) or in millimoles/litre (mmol/L).
With potassium
The anion gap is calculated by subtracting the serum concentrations of chloride and bicarbonate (anions) from
the concentrations of sodium and potassium (cations):
= ([Na+] + [K+]) ([Cl] + [HCO3])
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Omission of potassium has become widely accepted, as potassium concentrations, being very low, usually have
little effect on the calculated gap. This leaves the following equation:
= [Na+] ([Cl] + [HCO3]) =16 meq/lit
Uses
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 (Mg2+).
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 (HCO3) and phosphate (PO43), while commonly 'unmeasured' anions
include sulfates 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 (uncharged), 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.
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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 cellular
metabolism by leukocytes (also known as white blood cells) 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 condition.
A high anion gap indicates that there are, usually due to disease, elevated levels of anions like lactate, betahydroxybutyrate and acetoacetate, PO43, and SO42. These anions are not part of the anion-gap calculation and
therefore a high anion gap results. There is a secondary loss of HCO3 which is a buffer, without a concurrent
increase in Cl. Electroneutrality is therefore maintained. Thus, the presence of a high anion gap should result in
a search for conditions that lead to an excess of these anions.
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MUDPALES with the "A" representing alcoholic ketoacidosis. However, these are outdated and include low
yield items that are no longer in use. Historically, the "P" in these mnemonics stood for paraldehyde. As
paraldehyde is no longer used medically, the "P" often refers to propylene glycol. Additionally, three new
organic anion-gap-generating acids and acid precursors have been recognized since the initial acronym was
created. D-lactic acidosis occurs in patients with short bowel syndromes; 5-oxoproline (or pyroglutamic acid) is
associated with chronic acetaminophen use by malnourished women; and propylene glycol infusions, often used
as the solvent for several parenteral medications including lorazepam, phenobarbital, and others is metabolised
to D-lactate and L-lactate. These changes and additions required an update to the mnemonic. Thus, GOLD
MARK has been suggested for use by nephrologists in the 21st century.[12] This acronym represents glycols
(ethylene glycol and propylene glycol), oxoproline, L-lactate, D-lactate, methanol, aspirin, renal failure, and
ketoacidosis. Finally, another mnemonic CUTE DIMPLES includes cyanide, toluene, and a second "E" for
ethanol (alcoholic ketoacidosis) (cyanide, uremia, toluene, ethanol, diabetic ketoacidosis, isoniazid, methanol,
propylene glycol, lactic acidosis, ethylene glycol, salicylates). Perhaps the easiest mnemonic is KULT: ketones,
uremia, lactate and toxins, because these are the most common causes of a high anion gap metabolic acidosis
(HAGMA). The mnemonic for the (rare, in comparison) toxins is ACE GIFTs: aspirin, cyanide, ethanolic
ketosis, glycols (ethylene and propylene), isoniazid, ferric iron, toluene.
http://en.wikipedia.org/wiki/Anion_gap
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Note: a useful mnemonic to remember this is FUSEDCARS (fistula (pancreatic), uretero-enterostomy, saline
administration, endocrine (hyperparathyroidism), diarrhea, carbonic anhydrase inhibitors (acetazolamide),
ammonium chloride, renal tubular acidosis, spironolactone)
References
1. Oh MS, Carroll HJ (1977). "The anion gap". N. Engl. J. Med. 297 (15): 8147. doi:10.1056/NEJM197710132971507
(https://dx.doi.org/10.1056%2FNEJM197710132971507). PMID 895822
(https://www.ncbi.nlm.nih.gov/pubmed/895822).
2. Gabow PA, Kaehny WD, Fennessey PV, Goodman SI, Gross PA, Schrier RW (1980). "Diagnostic importance of an
increased serum anion gap". N. Engl. J. Med. 303 (15): 8548. doi:10.1056/NEJM198010093031505
(https://dx.doi.org/10.1056%2FNEJM198010093031505). PMID 6774247
(https://www.ncbi.nlm.nih.gov/pubmed/6774247).
3. Emmett M., Narins R.G. (1977). "Clinical use of the anion gap.". Medicine (56): 3854.
4. "Urine Anion Gap: Acid Base Tutorial, University of Connecticut Health Center"
(http://fitsweb.uchc.edu/student/selectives/TimurGraham/Urine_Anion_Gap.html). Archived
(http://web.archive.org/web/20081121214116/http://fitsweb.uchc.edu/student/selectives/TimurGraham/Urine_Anion_Ga
p.html) from the original on 21 November 2008. Retrieved 14 November 2008.
5. "Urine anion and osmolal gaps in metabolic acidosis" (http://www.uptodate.com/patients/content/topic.do?
topicKey=fldlytes/28741). Retrieved 14 November 2008.
6. Kirschbaum B, Sica D, Anderson FP (June 1999). "Urine electrolytes and the urine anion and osmolar gaps". The
Journal of Laboratory and Clinical Medicine 7604 133: 597604. doi:10.1016/S0022-2143(99)90190-7
(https://dx.doi.org/10.1016%2FS0022-2143%2899%2990190-7). PMID 10360635
(https://www.ncbi.nlm.nih.gov/pubmed/10360635).
7. 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): 3113. doi:10.1001/archinte.150.2.311 (https://dx.doi.org/10.1001%2Farchinte.150.2.311).
PMID 2302006 (https://www.ncbi.nlm.nih.gov/pubmed/2302006).
8. Kraut JA, Madias NE (2006). "Serum Anion Gap: Its Uses and Limitations in Clinical Medicine"
(http://cjasn.asnjournals.org/content/2/1/162.full.pdf+html) (PDF). Clinical Journal of the American Society of
Nephrology 2 (1): 162174. doi:10.2215/CJN.03020906 (https://dx.doi.org/10.2215%2FCJN.03020906).
PMID 17699401 (https://www.ncbi.nlm.nih.gov/pubmed/17699401).
http://en.wikipedia.org/wiki/Anion_gap
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External links
Clinical Physiology of Acid-Base and Electrolyte Disorders (http://books.mcgraw-hill.com/getbook.php?
isbn=0071346821&template=medical)
Intensive Care Medicine (http://www.lww.com/product/?0-7817-3548-3)
The ICU Book (http://www.lww.com/product/?0-683-05565-8)
Calculator at mcw.edu (http://www.intmed.mcw.edu/clincalc/aniongap.html)
Metabolic acidosis by Merck (http://www.merck.com/mmpe/sec12/ch157/ch157c.html)
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Categories: Acidbase disturbances Electrolyte disturbances
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