Anion-Gap Metabolic Acidosis, Causes and Differential Diagnosis (MUD PILES / GOLD MARK)

ACID-BASE DISTURBANCES, DDx, MNEMONICS

A) Causes of Increased Anion Gap Metabolic Acidosis

MUD PILERS

  • Methanol (antifreeze, windshield fluid, fuel, solvents), Ethanol, etc. Methanol is metabolized to formic acid. And formic acid gives off the H+ that is picked up by bicarb, leaving its conjugate base to raise the AG.
  • Uremia (renal failure)
  • DKA, alcoholic ketoacidosis
  • Paraldehyde –
  • Iron, Isoniazid (INH) – cause lactic acidosis.
  • Lactic acidosis (Type A, Type B, and D-lactic acidosis). “Lactic acidosis is the most common cause of metabolic in hospitalized patients.”A
  • Ethylene glycol (antifreeze),. Ethylene glycol is metabolized to glycolic and oxalic acids.
  • Renal Failure(RF), Rhabdomyolysis. RF leads to accumulation of organic anions such as phosphates, sulfates, urates, etc, which increase the AG.
  • Salicylates – cause metabolic acidosis and respiratory acidosis.

MA=Metabolic acidosis

MUD PILES

  • Methanol,
  • Uremia (renal failure)
  • Diabetic ketoacidosis,
  • Paraldehyde,
  • Iron, isoniazid (INH) – cause lactic acidosis.
  • Lactic acid,
  • Ethanol, ethylene glycol, diethylene glycol, or propylene glycol
  • Salicylates

GOLD MARK

  • Glycols (propylene glycol and ethylene glycol)
  • Oxoproline – 5-oxoproline (or pyroglutamic acid) is associated with chronic acetaminophen use, often by malnourished women.
  • L-lactate,
  • D-lactate – D-lactic acid can occur in some patients with short bowel syndromes
  • Methanol,
  • Aspirin,
  • Renal failure (vs. uremia)
  • Ketoacidosis (DKA, alcoholic ketoacidosis)

See GOLD MARK vs. MUD PILES.

 

Resources and Notes

A). https://www.uptodate.com/contents/causes-of-lactic-acidosis

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