Anion gap

Anion Gap:

Based on the concept of electroneutrality; the

assumption that the sum of all available cations= the
sum of all available anions. Restated as:

Na+ + Unmeasured Cations (UC) = Cl- + HCO3 +

Unmeasure Anions (UA); conventionally restated:

Na+-(Cl-+HCO3)=UA-UC=Anion Gap=12 (+/-2)

Anion Gap (AG):

The

calculated difference between the

positively charged (cations) and negatively
charged (anions) electrolytes in the body:

AG= Na+ - (Cl- + HCO3 -)

Normal

AG = 12 2 (10 14)

Unmeasured Anions/Cations

Anion Gap: Correction factor

Na+-(Cl-+HCO3)=UA-UC

Serum albumin contributes ~1/2 of the total anion

equivalency of the UA pool.
1gm/dl decline in serum albumin decreases the
anion gap factitiously by 3 mEq/L.
AG of 12 mEq/L is corrected to 17-18 mEq/L when
the serum albumin is half of normal; (chronic illness
or malnourished patients)

the anion gap. If the anion gap is

20, there is a primary metabolic acidosis
regardless of pH or serum bicarbonate
concentration

Calculate

Principle: The body does not generate a large

anion gap to compensate for a primary
disorder (anion gap must be primary)

So,
presence of an anion gap 20 is highly
predictive of the presence of an underlying
identifiable primary metabolic acidosis

The

Causes of Anion Gap Acidosis:

Endogenous

Uremia (uncleared organic acids)

Ketoacidosis, Lactic acidosis (increased organic
acid production), Rhabdomyolosis

Exogenous

acidosis

ingestions: salicylate, iron; paraldehyde use

Other

acidosis

Ingestions:

Methanol toxicity, Ethylene Glycol toxicity

Causes of High Anion Gap Metabolic

Acidosis: Lactic Acidosis
Increased

tissue lactate production

congenital defects
tissue hypoxia
enhanced metabolic rate

Decreased

lactate utilization

hypoperfusion
liver disease
ethanol intoxication

Causes of Hyperchloremic Metabolic

Acidosis
Impaired

renal failure
classic distal RTA (type I)
hyperkalemic distal RTA (type IV)

Renal

renal acid excretion

bicarbonate loss

proximal RTA (type II)

carbonic anhydrase inhibitors
therapy of diabetic ketoacidosis

Causes of Hyperchloremic Metabolic

Acidosis
Gastrointestinal

diarrhea
pancreatic drainage
ureteral diversion

Acid

bicarbonate loss

gain

hyperalimentation fluids
ammonium chloride ingestion

Determine Delta Anion Gap

Calculate the excess (delta) anion gap (total anion gap

normal anion gap) and add this value to the measured
bicarbonate concentration:

if the sum is > than normal bicarbonate (> 30) there is an

underlying metabolic alkalosis
if the sum is less than normal bicarbonate (< 23) there is an
underlying nonanion gap metabolic acidosis
1. Excess AG = Total AG Normal AG (12)
2. Excess AG + measured HCO3 = > 30 or < 23?

Principle: 1 mmol of unmeasured acid titrates 1 mmol of

bicarbonate ( anion gap = [ HCO3])

Why is this true?

For

each 1 mmol acid titrated by the carbonic

acid buffer system, 1 mmol of HCO3 is lost via
conversion to CO2 and H2O and 1 mmol of the
sodium salt of the unmeasured acid is formed.
1 mmol in HCO3 = 1mmol in AG
Therefore, the sum of the new (excess) anion
gap and the remaining (measured)
bicarbonate values should equal the normal
bicarbonate concentration

Excess Anion gap

HCO3 Added
If

Excess AG + Measured HCO3 = > normal HCO3

(30)
Then:

Some additional disorder has added HCO3 to the

extracellular space (metabolic alkalosis)

HCO3 Removed
If

Excess AG + Measured HCO3 = < normal HCO3

(23)
Then:

Some additional disorder has removed HCO3

from the extracellular space (nonanion gap
metabolic acidosis), e.g. renal or GI loses