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14-September-2008 18:02:45 - Anion gap The anion gap is used to aid in the differential diagnosis of metabolic acidosis. Contents 1 Calculation 2 Uses 3 Normal value ranges 4 Interpretation and causes 4.1 High anion gap 4.2 Normal anion gap hyperchloremic acidosis 4.3 Low anion gap 5 References 6 External links Calculation It is calculated by subtracting the serum concentrations of chloride and bicarbonate anions from the concentrations of sodium plus potassium cations: = Na++K+ - Cl-+HCO3- However, for daily practice, the potassium is frequently ignored, leaving the following equation: = Na+ - Cl-+HCO3- 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. The 'measured' cations are sodium Na+, Potassium K+, Calcium Ca2+ and Magnesium Mg2+. The 'unmeasured' cations include a few normally occurring serum proteins, and some pathological proteins e.g., paraproteins found in multiple myeloma. Likewise, the 'measured' anions are chloride Cl-, bicarbonate HCO3- and phosphate PO3-, with the 'unmeasured' anions being sulphates and a number of serum proteins predominantly albumin. By convention and for the sake of convenience only Na+, Cl- and HCO3- are used for calculation of the anion gap as noted above. In normal health there are more unmeasured anions compared to unmeasured cations in the serum, therefore the anion gap is usually positive. 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 helpful clinically, as it helps in the differential diagnosis of a number of disease states. Normal value ranges The average anion gap for healthy adults is 8-12. 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. 1In the past, methods for the measurement of the anion gap consisted of colorimetry for HCO3- and Cl- as well as flame photometry for Na+ and K+. Thus normal reference values ranged from 8 to 16 mmol/L plasma when not including K+ and from 10 to 20 mmol/L plasma when including K+. Some specific sources use 152 and 8-16 mEq/L.34Modern analyzers make use of ion-selective electrodes which give a normal anion gap as 11 mmol/L. Therefore according to the new classification system a high anion gap is anything above 11mmol/L and a normal anion gap is between 3-11 mmol/L.5 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 gap. A certain proportion of normal individuals may have values outside of the 'normal' range provided by any lab. Interpretation and causes 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. Eg, 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 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 an excess of these substances. High 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 replaced by the unmeasured anion resulting in a high anion gap. Lactic acidosis Ketoacidosis Diabetic ketoacidosis Alcohol abuse Toxins: Ethanol Ethylene glycol Lactic acid Methanol Paraldehyde Phenformin Aspirin Cyanide, coupled with elevated venous oxygenation Iron isoniazid Note: a useful mnemonic to remember this is MUDPILES methanol, uremia, DKA, paraldehyde, INH, lactic acidosis, ethylene glycol, salicylates Normal anion gap hyperchloremic 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 Renal loss of HCO3- i.e. proximal renal tubular acidosis Renal dysfunction i.e. renal failure, hypoaldosteronism, distal renal tubular acidosis Ingestions Ammonium chloride and Acetazolamide. 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. Note: a useful mnemonic to remember this is FUSEDCARS fistula pancreatic, uretogastric conduits, saline administration, endocrine hyperparathyrdoism, diarrhea, carbonic anhydrase inhibitors acetazolamide, ammonium chloride, renal tubular acidosis, spironolactone Low anion gap Unlike a high anion gap, obtaining a low anion gap is relatively rare. One of the most common causes of a low anion gap is a low albumin level which constitutes ~80% of the unmeasured anions. Correspondingly, an increase in the number of cations, either organic eg, paraproteins as in multiple myeloma or inorganic bromide, lithium, Iodine or polymyxin B can lead to low anion gap values. A decreased anion gap is also seen in multiple myeloma where the increased negatively-charged immunoglobulins interact with and bind cations in the blood References ^ Serum Anion Gap: Its Uses and Limitations in Clinical Medicine ^ Physiology at MCG 7/7ch12/7ch12p51 ^ The Anion Gap ^ Anion Gap: Acid Base Tutorial, University of Connecticut Health Center ^ 1 The Fall Of The Serum Anion Gap. External links 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 v d e Urinary system, physiology: renal physiology and acid base physiology Filtration Renal blood flow - Ultrafiltration - Countercurrent exchange Hormones affecting filtration Antidiuretic hormone ADH - Aldosterone - Atrial natriuretic peptide Secretion/clearance Pharmacokinetics - Clearance of medications Reabsorption Solvent drag - Na+ - Cl- - urea - glucose - oligopeptides - protein Endocrine Renin - Erythropoietin EPO - Calcitriol Active vitamin D - Prostaglandins Assessing Renal function/ Measures of dialysis Glomerular filtration rate - Creatinine clearance - Renal clearance ratio - Urea reduction ratio - Kt/V - Standardized Kt/V - Hemodialysis product - PAH clearance Effective renal plasma flow - Extraction ratio Acid base physiology Fluid balance - Darrow Yannet diagram - Body water - Interstitial fluid - Extracellular fluid - Intracellular fluid/Cytosol - Plasma - Transcellular fluid - Base excess - Davenport diagram - Anion gap - Arterial blood gas Buffering/compensation Bicarbonate buffering system - Respiratory compensation - Renal compensation Retrieved from http://en..org/wiki/Anion_gap Categories: Electrolyte disturbances | Intensive care medicine | Emergency medicine Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Deutsch Polski This page was last modified on 11 September 2008, at 19:47
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