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ANION GAP METABOLIC ACIDOSIS – STEPWISE APPROACH

⚠️ High anion gap metabolic acidosis (HAGMA)
→ Think extra unmeasured acids

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1️⃣ STEP 1: CHECK SERUM KETONES

➤ ↑ Ketones
  Hyperglycemia → Diabetic ketoacidosis
  Cachexia / fasting → Starvation ketoacidosis
  Alcohol use → Alcoholic ketoacidosis

➤ Normal ketones
  Check serum lactate

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2️⃣ STEP 2: LACTIC ACIDOSIS

➤ ↑ Lactate → Lactic acidosis
  With hypoperfusion → Type A lactic acidosis
  Without hypoperfusion → Type B lactic acidosis

➤ Normal lactate
  Check BUN & Creatinine
  ↑ BUN / Cr → Renal failure (uremia)

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3️⃣ STEP 3: SUSPECT TOXIC INGESTION

➤ Perform toxicology screen
➤ Check serum osmolal gap

➤ ↑ Osmolal gap
  Visual symptoms → Methanol ingestion
  Oxalate crystalluria → Ethylene glycol ingestion

➤ Normal osmolal gap
  Respiratory alkalosis → Aspirin toxicity

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4️⃣ HIGH-YIELD TOXIC CLUES

➤ Ethylene glycol
  Urine Ca²⁺ oxalate crystals (envelope-shaped)

➤ Methanol
  Vision loss, optic disc hyperemia

➤ Both
  ↑ Osmolal gap
  (Measured − calculated osm > 10 mOsm/L)

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💡 EXAM PEARL

➤ HAGMA = Ketoacidosis + Lactic acidosis + Renal failure + Toxins

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Fracture Descriptors

02/02/2026

Acute Renal Failure (AKI) Vs. Chronic Renal Failure (CKD)

🩺 Acute Renal Failure (AKI)

Definition: Sudden ↓ kidney function (hours → days)

⏱ Onset

✅ Rapid (hours/days)

🔥 Symptoms
• ↓ urine (oliguria) or sometimes normal urine
• Nausea, vomiting, confusion
• Fluid overload (edema, SOB)

🧪 Labs
• Creatinine rises quickly
• BUN/Cr depends on cause (often ↑ in prerenal)

🧬 Kidney size (Ultrasound)

✅ Normal or enlarged

💉 Common causes

P-R-I
• Pre-renal: dehydration, shock, heart failure
• Renal: ATN, nephritis, drugs (NSAIDs, aminoglycosides)
• Post-renal: obstruction (BPH, stones)

⚡ Complications
• Hyperkalemia (dangerous arrhythmia)
• Metabolic acidosis
• Pulmonary edema

✅ Often reversible if treated early

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🧑‍⚕️ Chronic Renal Failure (CKD)

Definition: Gradual kidney damage ≥ 3 months

⏳ Onset

✅ Slow (months/years)

😴 Symptoms
• Fatigue, weakness
• Itching (uremia)
• Poor appetite, weight loss
• Nocturia (early), later ↓ urine

🧪 Labs
• Creatinine elevated for long time
• Persistent proteinuria
• Low Hb (anemia) due to ↓ EPO
• Low Ca + High phosphate → bone disease

🧬 Kidney size (Ultrasound)

✅ Small shrunken kidneys (classic)
⚠️ Exception: diabetic nephropathy, polycystic kidney → may be enlarged

📌 Common causes
• Diabetes mellitus (most common)
• Hypertension
• Chronic glomerulonephritis
• Polycystic kidney disease

🧱 Complications
• Anemia
• Bone disease (renal osteodystrophy)
• Uremic symptoms
• Long-term fluid + electrolyte imbalance

❌ Usually not reversible, progresses slowly

01/02/2026

Important information,,,,