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      A Simple Estimate of the Effect of the Serum Albumin Level on the Anion Gap

      ,

      American Journal of Nephrology

      S. Karger AG

      Intensive care, Anion gap, Serum albumin, Serum t[CO2]

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          Abstract

          Background: The serum anion gap (serum [Na<sup>+</sup>]-Cl<sup>-</sup>]-[CO<sub>2</sub>]) is still the first-line approach to metabolic acidosis. However, while it is generally acknowledged that hypoalbuminemia mandates a downward adjustment of the expected anion gap, a specific correction factor for the anion gap in the face of low serum albumin has never been demonstrated. Methods: We reviewed initial laboratory data from 432 consecutive patients admitted or transferred to the medical intensive care unit at Nassau County Medical Center over a 6-month period and correlated the serum albumin with the anion gap and the serum [tCO<sub>2</sub>] using multivariate analysis. We looked at the anion gap as a function of <Delta> (albumin), the difference between normal and actual serum albumin, defined as 4.0 - measured serum albumin g/dl. We also assessed [tCO<sub>2</sub>] as an independent variable. Results: For patients with normal or high serum tCO<sub>2</sub>, the ratio of change in anion gap (<Delta> anion gap) to <Delta> (albumin) was 1.46 and 1.45, respectively. For patients with serum tCO<sub>2</sub> <22 mEq/l this ratio was 1.89. In the latter group, anion gap was best predicted taking both <Delta> (albumin) and serum tCO<sub>2</sub> into account: anion gap = 36.2 - serum tCO<sub>2</sub> - 2.3*<Delta> (albumin) (r = 0.71, p < 0.0001). Conclusion: For intensive care patients with normal or high serum tCO<sub>2</sub> (>21 mEq/l) a simple bedside adjustment of the anion gap by subtracting 1.5 times the difference between measured serum albumin and the 'normal' level of 4.0 g/dl gives a close estimate of the actual anion gap. For intensive care patients with serum tCO<sub>2</sub> <22 mEq/l, correction of the anion gap is well predicted by adding about twice the <Delta> (albumin) to the calculated gap.

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          The fall of the serum anion gap.

          Using modern electrode technology (Beckman ASTRA analyzer), we evaluated the reference range for the anion gap (calculated as sodium minus chloride minus bicarbonate concentrations) in serum to determine whether the 8 to 16 mmol/L reference range in common use is still valid. After measurement of electrolytes in (1) serum from 29 healthy volunteers, (2) aqueous standards verified against National Bureau of Standards reference material, and (3) serum from 120 blood donors, we drew the following conclusions. (1) The reference range for the anion gap has shifted downward (to 3 to 11 mmol/L in one of our laboratories), primarily because of an upward shift in chloride values. (2) Using the ASTRA analyzer, a majority of normal individuals can be expected to have serum anion gaps of 6 mmol/L or less unless chloride calibration is deliberately altered. (3) If the anion gap is to remain an effective tool in diagnosing acid-base disorders, clinicians need to be aware that the traditional reference range may not be appropriate with new instrumentation.
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            Author and article information

            Journal
            AJN
            Am J Nephrol
            10.1159/issn.0250-8095
            American Journal of Nephrology
            S. Karger AG
            0250-8095
            1421-9670
            2000
            October 2000
            15 November 2000
            : 20
            : 5
            : 369-372
            Affiliations
            Department of Medicine, Nassau County Medical Center, East Meadow, N.Y. and State University of New York Health Sciences Center, Stony Brook, N.Y., USA
            Article
            13618 Am J Nephrol 2000;20:369–372
            10.1159/000013618
            11092993
            © 2000 S. Karger AG, Basel

            Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

            Page count
            Figures: 1, Tables: 2, References: 7, Pages: 4
            Product
            Self URI (application/pdf): https://www.karger.com/Article/Pdf/13618
            Categories
            Clinical Study

            Cardiovascular Medicine, Nephrology

            Serum t[CO2], Serum albumin, Anion gap, Intensive care

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