High osmolar gap metabolic acidosis differential diagnosis

Jump to: navigation, search


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

High Osmolar Gap Metabolic Acidosis Differential Diagnosis

Differential diagnosis of metabolic acidosis and lactic acidosis is as follow:[1][2][3][4]

To review differential diagnosis of metabolic acidosis, click here.

Category Disease Mechanism Clinical Paraclinical Gold standard diagnosis Other findings
Symptoms Signs Lab data
ABG CBC Chemistry Renal U/A
↑ acid
production
Loss of
bicarbonate
↓ renal acid
excretion
Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3 paCO2 O2 WBC Hb BS Cl K+ Na+ Ketones Lactic acid Serum AG[5] Osmolar gap[6] Bun Cr Urine pH Urine AG Urine ketone
Toxin/Medication[7] Alcohol poisoning[8][9] + + + ↓ ↑ + Nl Nl Nl + Nl or ↑ Nl or ↑ + + Clinical manifestation
+ + + + Nl Nl Nl Nl + Nl Nl Nl or ↑ + + Clinical manifestation
  • Not applicable
Salicylates overdose[11] + + + + + ↓↓ Nl Nl Nl to ↓ Nl Nl Clinical and elevated serum salicylate level
Metformin[12] + + + ± Agitated Nl Nl to ↑ Nl Nl Nl Nl Nl or ↑ Nl Clinical manifestation
Category Disease ↑ acid
production
Loss of
bicarbonate
↓ renal acid
excretion
Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3 paCO2 O2 WBC Hb BS Cl K+ Na+ Ketones Lactic acid Serum AG Osmolar gap Bun Cr Urine pH Urine AG Urine ketone Gold standard diagnosis Other findings
Ketoacidosis Diabetic ketoacidosis[13] + + + + + + + Nl to ↓ Nl to ↑ ↑↑ Nl Nl to ↑ Nl + + Clinical + hyperglycemia + ketosis
  • Labs might show elevated K+ even in K+ depletion due to extravasation of intracellular K+ in exchanged with extracellular H+
Alcoholic ketoacidosis (Ethanol)[14] + + ± + ↓ ↑ + Agitated Nl to ↑ Nl to ↑ ↓ Nl ↑ Nl ↑↑ ↑↑ Nl + + Clinical manifestation + ketosis
Systemic Lactic acidosis[15] + ± + + ↓ ↑ ± Agitated Nl to ↑ Nl Nl Nl Nl Nl Nl or ↑ Nl Clinical manifestation and lab finding
  • Not applicable
Renal Uremia[16] + + + + ↓ ↑ ± Nl to ↓ Nl Nl Nl Nl + Clinical manifestation and lab finding
Renal failure[17] + + + + Nl to ↓ Nl Nl Nl Renal function test
  • Not applicable
Category Disease ↑ acid
production
Loss of
bicarbonate
↓ renal acid
excretion
Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3 paCO2 O2 WBC Hb BS Cl K+ Na+ Ketones Lactic acid Serum AG Osmolar gap Bun Cr Urine pH Urine AG Urine ketone Gold standard diagnosis Other findings

References

  1. Lim S (2007). "Metabolic acidosis". Acta Med Indones. 39 (3): 145–50. PMID 17936961.
  2. Morris, C. G.; Low, J. (2008). "Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology". Anaesthesia. 63 (3): 294–301. doi:10.1111/j.1365-2044.2007.05370.x. ISSN 0003-2409.
  3. Morris CG, Low J (April 2008). "Metabolic acidosis in the critically ill: part 2. Causes and treatment". Anaesthesia. 63 (4): 396–411. doi:10.1111/j.1365-2044.2007.05371.x. PMID 18336491.
  4. Casaletto, Jennifer J. (2005). "Differential Diagnosis of Metabolic Acidosis". Emergency Medicine Clinics of North America. 23 (3): 771–787. doi:10.1016/j.emc.2005.03.007. ISSN 0733-8627.
  5. Brubaker RH, Meseeha M. High Anion Gap Metabolic Acidosis. [Updated 2017 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448090/
  6. Kraut JA, Xing SX (September 2011). "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". Am. J. Kidney Dis. 58 (3): 480–4. doi:10.1053/j.ajkd.2011.05.018. PMID 21794966.
  7. Pham, Amy Quynh Trang; Xu, Li Hao Richie; Moe, Orson W. (2015). "Drug-Induced Metabolic Acidosis". F1000Research. doi:10.12688/f1000research.7006.1. ISSN 2046-1402.
  8. Zehtabchi S, Sinert R, Baron BJ, Paladino L, Yadav K (2005). "Does ethanol explain the acidosis commonly seen in ethanol-intoxicated patients?". Clin Toxicol (Phila). 43 (3): 161–6. PMID 15902789.
  9. Roberts, Darren M.; Yates, Christopher; Megarbane, Bruno; Winchester, James F.; Maclaren, Robert; Gosselin, Sophie; Nolin, Thomas D.; Lavergne, Valéry; Hoffman, Robert S.; Ghannoum, Marc (2015). "Recommendations for the Role of Extracorporeal Treatments in the Management of Acute Methanol Poisoning". Critical Care Medicine. 43 (2): 461–472. doi:10.1097/CCM.0000000000000708. ISSN 0090-3493.
  10. Ashurst JV, Nappe TM. Toxicity, Isopropanol. [Updated 2018 Mar 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493181/
  11. Wright, Dallas; Sop, Jessica (2015). "Normal anion gap salicylate poisoning". The American Journal of Emergency Medicine. 33 (11): 1714.e3–1714.e4. doi:10.1016/j.ajem.2015.03.042. ISSN 0735-6757.
  12. Galiero, Francesca; Consani, Giovanni; Biancofiore, Gianni; Ruschi, Stefano; Forfori, Francesco (2018). "Metformin intoxication: Vasopressin's key role in the management of severe lactic acidosis". The American Journal of Emergency Medicine. 36 (2): 341.e5–341.e6. doi:10.1016/j.ajem.2017.10.057. ISSN 0735-6757.
  13. Wolfsdorf, Joseph I; Allgrove, Jeremy; Craig, Maria E; Edge, Julie; Glaser, Nicole; Jain, Vandana; Lee, Warren WR; Mungai, Lucy NW; Rosenbloom, Arlan L; Sperling, Mark A; Hanas, Ragnar (2014). "Diabetic ketoacidosis and hyperglycemic hyperosmolar state". Pediatric Diabetes. 15 (S20): 154–179. doi:10.1111/pedi.12165. ISSN 1399-543X.
  14. Howard RD, Bokhari S. PMID 28613672. Vancouver style error: initials (help); Missing or empty |title= (help)
  15. Kraut, Jeffrey A.; Ingelfinger, Julie R.; Madias, Nicolaos E. (2014). "Lactic Acidosis". New England Journal of Medicine. 371 (24): 2309–2319. doi:10.1056/NEJMra1309483. ISSN 0028-4793.
  16. Brown, Denver; Melamed, Michal L. (2018). "New Frontiers in Treating Uremic Metabolic Acidosis". Clinical Journal of the American Society of Nephrology. 13 (1): 4–5. doi:10.2215/CJN.11771017. ISSN 1555-9041.
  17. Kraut, Jeffrey A.; Madias, Nicolaos E. (2016). "Metabolic Acidosis of CKD: An Update". American Journal of Kidney Diseases. 67 (2): 307–317. doi:10.1053/j.ajkd.2015.08.028. ISSN 0272-6386.

Linked-in.jpg