EUH Krakow Conference: What are all of the causes of anion gap acidosis and are there mnemonics by which to remember them?

Bottom Line: Causes of anion gap metabolic acidosis are broken down into the following categories: overproduction of acid due to ketoacidosis or lactic acidosis, underexcretion of acid (such as due to advanced renal failure/chronic kidney disease (uremia)), cell lysis (such as due to massive rhabdomyolysis, penicillin-derived antibiotics, and pyroglutamic acid (5-oxoproline). Two mnemonics for remembering the causes are GOLDMARK and CAT MUD PILES.

Here is the full listing of causes from DynaMed Plus → Anion gap metabolic acidosis → Etiology and pathogenesis → Causes.

  • overproduction of acid, such as due to
    • ketoacidosis
      • uncontrolled diabetes
      • alcoholic ketoacidosis
      • starvation ketoacidosis
      • life-threatening ketoacidosis reported following strict adherence to Atkins diet (maintaining ketonuria for 1 month) in case report
      • inactivating mutations in monocarboxylate transporter 1 associated with increased ketoacidosis severity in genetic analysis of 96 patients
    • lactic acidosis
      • type A L-lactic acidosis – hypoxic lactic acidosis, causes include
        • septic shock
        • hypovolemic shock
        • acute mesenteric ischemia
        • cyanide poisoning
        • carbon monoxide poisoning
      • type B L-lactic acidosis – nonhypoxic lactic acidosis, causes include
        • thiamine deficiency
        • seizure
        • poor lactate clearance due to liver failure
        • glycogen storage diseases
        • malignancy such as Hodgkin lymphoma (HL)
        • medications and drugs
          • propofol
          • metformin
          • niacin
          • nucleoside reverse transcriptase inhibitors
          • isoniazid toxicity
          • iron toxicity
          • aspirin intoxication
          • ethanol intoxication (different than alcoholic ketoacidosis)
          • methanol poisoning
          • isopropyl alcohol poisoning
          • ethylene glycol poisoning
          • paraldehyde poisoning
          • propylene glycol intake
          • early toluene intake
  • underexcretion of acid, such as due to advanced renal failure/chronic kidney disease (uremia)
  • cell lysis, such as due to massive rhabdomyolysis
  • penicillin-derived antibiotics
  • pyroglutamic acid (5-oxoproline)

Reference: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 116876, Anion gap metabolic acidosis; [updated 2015 Oct 27, cited 2017 Aug 3].

Pneumonics:

Provided by Dr. David Krakow
GOLDMARK
  • G – glycols -ethylene glycol ( antifreeze) and propylene glycol (solvent for lorazepam among other uses)
  • O – oxoproline (tylenol use in sick,  malnourished patient)
  • L –  L Lactate
  • D – D  Lactate (consider in patient with risk for bacterial overgrowth who gets confused after carbohydrate load)
  • M – methanol
  • A – aspirin (salicylates)
  • R – renal failure
  • K – ketoacidosis (DKA, AKA, starvation ketoacidosis)

From DynaMed Plus → Anion gap metabolic acidosis → Etiology and pathogenesis → Causes.

CAT MUD PILES

  • C – carbon monoxide, cyanide
  • A – alcoholic ketoacidosis (starvation ketoacidosis)
  • T – toluene (can cause both normal anion gap and elevated anion gap acidosis)
  • M – methanol, metformin
  • U – uremia
  • D – diabetic ketoacidosis
  • P – propylene glycol, paraldehyde, phenformin
  • I – isoniazid, iron
  • L – lactic acidosis
  • E – ethylene glycol, ethanol
  • S – salicylates
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About Lisa

I have been a Clinical Informationist (aka Medical Librarian) for Emory University since September 2013. Prior to that, I was a Medical Librarian for Lincoln Memorial University (LMU) from March 2007 to August 2013 and served its DeBusk College of Osteopathic Medicine, Caylor School of Nursing, and allied health programs. From January 2002 - March 2007, I served the Medical Assisting (MA), Occupational Therapy Assistant, Physical Therapy Assistant, Radiologic Technologist, and Nursing programs at South College in Knoxville, Tennessee. I graduated from The University of Tennessee School of Information Sciences with a Master of Science degree in December 2000.
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