Diagnostic Importance of an Increased Serum Anion Gap

Gabow, Patricia A.; Kaehny, William D.; Fennessey, Paul V.; Goodman, Stephen I.; Groß, Peter; Schrier, Robert W.

doi:10.1056/nejm198010093031505

Cited by 182 publications

(92 citation statements)

References 16 publications

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“…Serum formate and glycolate levels have been determined to assess the response to therapy in some clinical studies of methanol and ethylene glycol intoxications (14,28,43,61,62). However, serum formate and or glycolate levels cannot be obtainable routinely in most clinical laboratories; therefore, in selected cases, examination of the serum anion gap can be used instead to determine the impact of treatment on the levels of these toxic metabolites (1,2,12,23).…”

Section: General Principles Of Treatmentmentioning

confidence: 99%

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Toxic Alcohol Ingestions

Kraut¹,

Kurtz²

2008

Clinical Journal of the American Society of Nephrology

355

326

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Alcohol-related intoxications, including methanol, ethylene glycol, diethylene glycol, and propylene glycol, and alcoholic ketoacidosis can present with a high anion gap metabolic acidosis and increased serum osmolal gap, whereas isopropanol intoxication presents with hyperosmolality alone. The effects of these substances, except for isopropanol and possibly alcoholic ketoacidosis, are due to their metabolites, which can cause metabolic acidosis and cellular dysfunction. Accumulation of the alcohols in the blood can cause an increment in the osmolality, and accumulation of their metabolites can cause an increase in the anion gap and a decrease in serum bicarbonate concentration. The presence of both laboratory abnormalities concurrently is an important diagnostic clue, although either can be absent, depending on the time after exposure when blood is sampled. In addition to metabolic acidosis, acute renal failure and neurologic disease can occur in some of the intoxications. Dialysis to remove the unmetabolized alcohol and possibly the organic acid anion can be helpful in treatment of several of the alcohol-related intoxications. Administration of fomepizole or ethanol to inhibit alcohol dehydrogenase, a critical enzyme in metabolism of the alcohols, is beneficial in treatment of ethylene glycol and methanol intoxication and possibly diethylene glycol and propylene glycol intoxication. Given the potentially high morbidity and mortality of these intoxications, it is important for the clinician to have a high degree of suspicion for these disorders in cases of high anion gap metabolic acidosis, acute renal failure, or unexplained neurologic disease so that treatment can be initiated early. Table 1. Methanol, ethylene glycol, diethylene glycol, and propylene glycol intoxication and alcoholic ketoacidosis can produce hyperosmolality and metabolic acidosis (3-9). Isopropanol intoxication is usually associated with hyperosmolality alone (4,5). Importantly, several of these disorders can be fatal or produce irreversible tissue damage if they are not quickly recognized and treated appropriately (4 -15). Effect of Alcohols on Serum Osmolality and the Osmolal GapThe normal serum osmolality of 285 to 290 mOsm/L is due to sodium and its counterbalancing ions, bicarbonate and chloride, and glucose and urea. It can be calculated using the following equation:Serum osmolality (mOsm/L) ϭ 2 ϫ Na ϩ ϩ blood urea nitrogen (mg/dl)/2.8 ϩ glucose (mg/dl)/18. The serum osmolality measured by freezing point depression is usually within 10 mOsm/L of the calculated serum osmolality (16). Accumulation of low molecular weight substances in the serum (such as each of the alcohols) will raise the measured serum osmolality above that of the calculated serum osmolality, producing an osmolal gap (4,5,16 -18). The effect of each of the alcohols on serum osmolality is shown in Table 2. Methanol gives rise to the greatest increment in serum osmolality, followed by ethanol, isopropanol, ethylene glycol, propylene glycol, and diethylene glycol in that...

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Section: General Principles Of Treatmentmentioning

confidence: 99%

“…L actic acidosis and diabetic ketoacidosis (DKA) are the most common causes of acute metabolic acidosis (1,2). Much less frequent but of great importance clinically are the alcohol intoxications shown in Table 1.…”

mentioning

confidence: 99%

Toxic Alcohol Ingestions

Kraut¹,

Kurtz²

2008

Clinical Journal of the American Society of Nephrology

355

326

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“…Therefore, changes in its concentration and dissociation will lead to a corresponding change in the anion gap. Gabow et al [94] proposed that the anion gap is decreased by a factor of 2.5 mmol.l 21 for every 1 g.dl 21 decrease in albumin, and this has been validated scientifically [95]. However, it has not yet been shown that hypoalbuminaemia can mask a significant anion gap acidosis [96].…”

Section: Anion Gapmentioning

confidence: 98%

“…Other osmotically active substances must be present and it is worth noting from the outset that if the anion gap is . 25 mmol.l 21 , an organic cause is likely [94]. A lactate level can be easily measured in most hospitals and a toxicology screen normally excludes the more common poisons such as alcohol and salicylates.…”

Section: Significance Of the Anion Gapmentioning

confidence: 99%

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Anions and the anaesthetist

2002

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SummaryAnions are the negative components of most chemical structures and play many important physiological and pharmacological roles that are of interest to the anaesthetist. Their relevance is reviewed with a particular emphasis on the inorganic anions (halides, bicarbonate, phosphate and sulphate) and the significance and limitations of the anion gap. Organic anions (albumin, lactate) are also discussed, albeit briefly. The suitability of anions for their role in neurotransmission and acid2base balance is outlined.

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The Fall of the Serum Anion Gap

Winter¹

1990

Arch Intern Med

121

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Diagnostic Importance of an Increased Serum Anion Gap

Cited by 182 publications

References 16 publications

Toxic Alcohol Ingestions

Toxic Alcohol Ingestions

Anions and the anaesthetist

The Fall of the Serum Anion Gap

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