METABOLIC ALKALOSIS
✿ Increased renal h+ excretion/ hco3- reabsorption
✧ mineralocorticoids excess
☼ primary hyperaldosteronism
⁎ adrenal tumor
⁎ ectopic aldosterone-secreting tumor
⁎ familial hyperaldosteronism
☼ secondary hyperaldosteronism
⁎ renal artery stenosis
⁎ accelerated hypertension
⁎ renin-secreting tumor
⁎ estrogen therapy
☼ exogenous mineralocorticoids (fludrocortisone)
✧ cortisol excess
⁎ 11β-hydroxysteroid dehydrogenase deficiency
⁎ licorice overingestion
⁎ antifungals (posaconazole, itroconazole)
⁎ Ectopic acth syndrome
✧ inherited tubulopathies
☼ liddle' syndrome
☼ bartter syndrome
☼ gitelman syndrome
☼ pendred syndrome
✧ drugs (diuretics, penicillin)
✧ volume depletion
✧ chronic respiratory acidosis
✧ milk-alkali syndrome
✿ gi hco3- gain
✧ bicarb tabs
✧ antacids + cation-exchange resins (kayexalate)
✧ longterm tube feeds
✿ gi h+ / cl- loss
✧ vomiting
✧ nasogastric tube suctioning
✧ laxative abuse
✧ villous adenoma
✧ congenital chloride diarrhea (chloridorrhea)
✿ skin cl- loss
✧ cystic fibrosis
✿ intracellular h+ shift
✧ severe hypoklalemia
✿ intravenous infusion of alkali compounds
✧ sodium bicarb
✧ sodium citrate
☼ blood transfusion
☼ plasmapheresis
METABOLIC ACIDOSIS
ELEVATED ANION GAP
✿ Ingestion of acid-producing substance
✧ glycols (ethylene or propylene glycol)
✧ methanol
✧ acetaminophen (chronic use)
✧ salicylate (aspirin)
✿ Cell / tissue acid production
✧ ketoacidosis
☼ diabetic ketoacidosis
☼ fasting ketoacidosis
☼ alcoholic ketoacidosis
✧ lactic acidosis
☼ hypoperfusion (type a)
⁎ hypotension / shock / arrest
⁎ ischemia
☼ impaired cellular metabolism (type b)
⁎ sepsis
⁎ liver dysfunction
⁎ seizure
⁎ malignancy
⁎ metformin
⁎ β-agonists (epinephrine, albuterol)
⁎ nucleoside reverse transcriptase inhibitors
⁎ methanol, ethylene glycol
⁎ thamine deficiency (s/p high glucose load)
⁎ congenital mitochondrial defects
✧ d-lactic acidosis
☼ short bowel syndrome (s/p large carb load)
☼ propylene glycol (high dose benzo infusion)
✿ Decreased renal acid excretion
✧ renal failure / esrd
NORMAL ANION GAP
✿ Hco3- dilution by extracellular volume expansion
✧ normal saline ivf
✧ total parenteral nutrition
✿ GI hco3- loss
✧ diarrhea
✧ small bowel or pancreatic fistula
✧ ureteral diversion (to colon, ileum)
✿ Decreased renal hco3- reabsorption / h+ excretion
✧ renal insufficiency / ckd
✧ carbonic anhydrase inhibitors (acetazolamide)
✧ renal tubular acidosis
☼ type 1 (hypokalemic distal) rta
⁎ sjogren
⁎ medullary intersitial disease
⁎ hypercalciuria
⁎ drugs (amphotericin, lithium, ifosfamide)
☼ type 2 (proximal) rta
⁎ monoclonal gammopathy / light chain disease
⁎ drugs (acetazolamide, topiramate, chemo)
⁎ heavy metals (lead, copper, mercury)
⁎ renal transplant
⁎ obstructive uropathy
⁎ paroxysmal nocturnal hemoglobinuria
⁎ wilson disease
☼ type 4 (hypoaldosteronism) rta
⁎ hyporeninemia (diabetes)
⁎ adrenal insufficiency
⁎ drugs (nsaids, calcineurin inhibitors, ace/arb, chronic heparin, k-sparing diuretics, trimethoprim)
⁎ pseudohypoaldosteronism
☼ voltage-dependent rta
⁎ severe hypovolemia
⁎ obstructive uropathy
⁎ lupus nephritis
⁎ sickle cell disease
