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Normochloremic metabolic acidosis generally results from addition of organic acids such as lactate, acetoacetate, beta-hydroxybutyrate, and exogenous toxins. Other anions such as isocitrate, alpha-ketoglutarate, malate, and D-lactate may contribute to the anion gap of lactic acidosis, DKA, and acidosis of unknown etiology. Uremia causes an increased anion gap metabolic acidosis from unexcreted organic acids and anions.

A. Lactic Acidosis

Lactic acidosis is a common cause of metabolic acidosis, producing an elevated anion gap and decreased serum pH when present without other acid-base disturbances. Lactate is formed from pyruvate in anaerobic glycolysis. Normally, lactate levels remain low (1 mEq/L) because of metabolism of lactate principally by the liver through gluconeogenesis or oxidation via the Krebs cycle.

In lactic acidosis, lactate levels are at least 4–5 mEq/L but commonly 10–30 mEq/L. There are two basic types of lactic acidosis.

Type A (hypoxic) lactic acidosis is more common, resulting from decreased tissue perfusion; cardiogenic, septic, or hemorrhagic shock; and carbon monoxide or cyanide poisoning. These conditions increase peripheral lactic acid production and decrease hepatic metabolism of lactate as liver perfusion declines.

Type B lactic acidosis may be due to metabolic causes (eg, diabetes, ketoacidosis, liver disease, kidney disease, infection, leukemia, or lymphoma) or toxins (eg, ethanol, methanol, salicylates, isoniazid, or metformin). Propylene glycol can cause lactic acidosis from decreased liver metabolism; it is used as a vehicle for intravenous drugs, such as nitroglycerin, etomidate, and diazepam. Parenteral nutrition without thiamine causes severe refractory lactic acidosis from deranged pyruvate metabolism. Patients with short bowel syndrome may develop d-lactic acidosis with encephalopathy due to carbohydrate malabsorption and subsequent fermentation by colonic bacteria. Nucleoside analog reverse transcriptase inhibitors can cause type B lactic acidosis due to mitochondrial toxicity.

Idiopathic lactic acidosis, usually in debilitated patients, has an extremely high mortality rate. (For treatment of lactic acidosis, see below and Chapter 27-05.)

B. Diabetic Ketoacidosis (DKA)

DKA is characterized by hyperglycemia and metabolic acidosis with an increased anion gap:

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where B is beta-hydroxybutyrate or acetoacetate, the ketones responsible for the increased anion gap. The anion gap should be calculated from the measured serum electrolytes; correction of the serum sodium for the dilutional effect of hyperglycemia will exaggerate the anion gap. Diabetics with ketoacidosis may have lactic acidosis from tissue hypoperfusion and increased anaerobic metabolism.

During the recovery phase of DKA, a hyperchloremic non-anion gap acidosis can develop because saline resuscitation results in chloride retention, restoration of GFR, and ketoaciduria. Ketone salts (NaB) are formed as bicarbonate is consumed:

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The kidney reabsorbs ketone anions poorly but can compensate for the loss of anions by increasing the reabsorption of Cl.

Patients with DKA and normal kidney function may have marked ketonuria and severe metabolic acidosis but only a ...

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