POLL: Your Anion Gap

what is your anion gap? A high Anion Gap can help Lactic Acidosis diagnosis

  • Too low

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  • Too high

    Votes: 1 20.0%
  • Normal

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    5

pattismith

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Too high anion gap means Acidosis and can happen if you have for example lactic acidosis

Too low anion gap is often related to low Albumine

Two ways for Anion Gap calculation, the usual formula is Na - Cl - HCO3

units are mmol/l or mEq/l

Normal is 8 to 16 (or 10 to 20 if K include)

1612728629410.png


HIGH ANION GAP:


1612728323220.png


1612729367850.png

And a method to remember high anion gap causes for docs:

1612730072902.png
 
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pattismith

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mine is 139 - 100 - 29.7 = 9.3 normal
or with K: 139 + 4.4 - 100 -29.7 = 13.7 normal

@Avenger has been diagnosed with D lactic acidosis and some other ME/CFS patients may be affected as well, so it's worth doing the Anion gap testing. (not an expensive test though)


A very interesting story, Avenger.

My first thought on reading it was that although full D-lactic acidosis like you experienced might be quite rare, and is almost certainly not the cause of ME/CFS in general, it is quite possible that some ME/CFS patients might have D-lactic acid-producing bacteria in their guts which may be exacerbating their ME/CFS symptoms.

Indeed, one study by KDM et al found that ME/CFS patients have higher amounts of D-lactic acid-producing bacteria.


It has been demonstrated in this study that D-lactic acid acts to block energy metabolism in brain and heart (but not liver) mitochondria. It is hypothesized this is due to D-lactic acid interfering with the utilization of L-lactate and pyruvate in mitochondria, leading to impairments in mitochondrial energy metabolism.

And this likely explains why D-lactic acid produces symptoms that closely resemble those of ME/CFS, since there is evidence to indicate mitochondrial energy metabolism is also impaired in ME/CFS.


So could lots of ME/CFS patients have D-lactic acid-producing bacteria in their guts which are adding to the burden of their symptoms?

Well, this interesting article about D-lactic acid ME/CFS says:


So it seems that most people do possess the D-lactate dehydrogenase enzyme which breaks down D-lactate dehydrogenase, and would thus not be susceptible (or less susceptible) to D-lactic acid toxicity.

In other words, even if you have high levels of D-lactic acid-producing bacteria in your guts, and D-lactic acid in your bloodstream, this may not on its own cause problems, unless you are also one of the very small percentage of the population who are unable to properly metabolize D-lactic acid, because you don't have sufficient mitochondrial D-lactate dehydrogenase.

Thus it might be interesting to do some further research, and find out if there are any known SNP genetic alleles (mutations) which lead to impaired D-lactate dehydrogenase production.

It would be good if people could look up their D-lactate dehydrogenase SNPs on 23andme.com, and work out whether they are one of the very small percentage of the population who are at risk of developing D-lactic acidosis, or milder issues with D-lactic acid, because they do not produce sufficient D-lactate dehydrogenase.
 

pamojja

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Have 3 times Anion gap (K+) test-results from blood-gas-anaylsis, normal range given is 3-11 mmol/l. In average 8.1. Though my blood pH seems to indicate otherwise, normal range 7.35-7.45

2015: 6.5 mmol/l - 7.48 pH
2017: 9.9 mmol/l - 7.47 pH
2018: 7.9 mmol/l - 7.43 pH
 

kangaSue

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As is so often the case with chronic disease, it's not always clear cut black and white and you can still have elevated levels of d-lactate with a normal anion gap.

https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-September-15.pdf
[D-lactate is not detected in standard clinical lactic acid assays and requires a specific request from the lab. Despite this, an elevated concentration of D-lactate in the plasma always causes acidosis and usually leads to an increased anion gap. However, the anion gap may be lower than one would expect with similar concentrations of L-lactate or may even be normal. A fraction of D-lactate is excreted with sodium or potassium in the urine, which may lead to a relative non-gap (or low strong ion difference) acidosis. A normal anion gap does not therefore definitively exclude D-lactic acidosis.]
 

WantedAlive

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mine is 139 - 100 - 29.7 = 9.3 normal
or with K: 139 + 4.4 - 100 -29.7 = 13.7 normal
@pattismith There can be hidden data in anion gap. While your measure is in the normal range, it certainly is low end of normal and verging toward metabolic alkalosis. Your bicarbonate is higher than the normal 21-28. My bicarbonate was same as yours at 30. I'd be interested in your blood gases. I'd suspect, like me, you have respiratory acidosis, and your anion gap is perhaps showing compensatory metabolic alkalosis.

Here's my chart showing acute respiratory acidosis. Others have shown similar. This is a venous test, I also had an arterial test which revealed normal, but a P(a-v)CO2 (PCO2 difference between arterial and venous) greater than 6 is considered hypo-perfusion. Mine was 20+!
1612828728877.png


What would be interesting is the composition of the 'gap' ions. You could still theoretically have low albumin with normal anion gap, but compensated for by other ions that are not listed or tested (that represent the gap). I'm also interested in your sodium measure - do you supplement sodium/salt when this test was taken? This is relevant to low blood volume, and whether its solely ADH or maybe low sodium levels play a part. I'm curious if there might be high intracellular sodium in ME/CFS.

What was your blood pH? As you can see mine venous was 7.26 versus a normal 7.45. My arterial pH was near normal. Was your anion gap test venous or arterial measure? Arterial only usually done in hospital, mine was done using the femoral artery.
 

pattismith

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As is so often the case with chronic disease, it's not always clear cut black and white and you can still have elevated levels of d-lactate with a normal anion gap.

https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-September-15.pdf
[D-lactate is not detected in standard clinical lactic acid assays and requires a specific request from the lab. Despite this, an elevated concentration of D-lactate in the plasma always causes acidosis and usually leads to an increased anion gap. However, the anion gap may be lower than one would expect with similar concentrations of L-lactate or may even be normal. A fraction of D-lactate is excreted with sodium or potassium in the urine, which may lead to a relative non-gap (or low strong ion difference) acidosis. A normal anion gap does not therefore definitively exclude D-lactic acidosis.]
Thank you for bringing this information, I think that anion gap is still a good screening test to do; And for those who are still not sure if lactic acidosis is involved, they can do a trial with low carbs:sugar I guess.



@pattismith There can be hidden data in anion gap. While your measure is in the normal range, it certainly is low end of normal and verging toward metabolic alkalosis. Your bicarbonate is higher than the normal 21-28. My bicarbonate was same as yours at 30. I'd be interested in your blood gases. I'd suspect, like me, you have respiratory acidosis, and your anion gap is perhaps showing compensatory metabolic alkalosis.

What would be interesting is the composition of the 'gap' ions. You could still theoretically have low albumin with normal anion gap, but compensated for by other ions that are not listed or tested (that represent the gap). I'm also interested in your sodium measure - do you supplement sodium/salt when this test was taken? This is relevant to low blood volume, and whether its solely ADH or maybe low sodium levels play a part. I'm curious if there might be high intracellular sodium in ME/CFS.

What was your blood pH? As you can see mine venous was 7.26 versus a normal 7.45. My arterial pH was near normal. Was your anion gap test venous or arterial measure? Arterial only usually done in hospital, mine was done using the femoral artery.
Hello thank you for taking some time reading my anion gap. I agree my bicarbonate are at the up limit. maybe you are right and that I do have alkalosis. I have no idea how to get tested for blood pH or blood gases however...
My sodium seems good to me, don't you agree?
 

WantedAlive

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Hello thank you for taking some time reading my anion gap. I agree my bicarbonate are at the up limit. maybe you are right and that I do have alkalosis. I have no idea how to get tested for blood pH or blood gases however...
My sodium seems good to me, don't you agree?
You should be able request a blood gases test, it's pretty standard. Although, because gases are very volatile it's important that they are analysed on site quickly after the blood is drawn, so that maybe limits where you can do it. Another thing is that it's normally done as an arterial test, but a venous test is still informative of your peripheral respiration. Blood pH is part of that test.

Out of interest I looked back at my early onset blood tests and I found my albumin at high end of normal. It'd be interesting what others show.

Yes, I agree your sodium is normal [135-145], and your chloride is normal [96-106], so no sign of concentration/dilution. I was just curious if you supplemented salt as many do, not that it might have changed anything anyway.
 

Avenger

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As is so often the case with chronic disease, it's not always clear cut black and white and you can still have elevated levels of d-lactate with a normal anion gap.

https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-September-15.pdf
[D-lactate is not detected in standard clinical lactic acid assays and requires a specific request from the lab. Despite this, an elevated concentration of D-lactate in the plasma always causes acidosis and usually leads to an increased anion gap. However, the anion gap may be lower than one would expect with similar concentrations of L-lactate or may even be normal. A fraction of D-lactate is excreted with sodium or potassium in the urine, which may lead to a relative non-gap (or low strong ion difference) acidosis. A normal anion gap does not therefore definitively exclude D-lactic acidosis.]
Hi, kangaSue;
yes, it is certainly not that simple and high levels of D-Lactate can also impair Kidney function, increasing the level of D-Lactate to a level that we cannot detoxify through the Pyruvate Chain; and I have always believed that there may be other variant forms of Organic Acids that act in a similar way to D-Lactate. Other Organic acids are produced by different Bacterial Overgrowth's and may account for differences in ME/ CFS/Fibromyalgia etc. Organic acids are simply neurotoxin's and poisons that will cause a miyriad of symptoms that cannot easily be measured, including low SpO2 and breathing difficulty;


I am interested in a possible simple signature that may be useful for some of us that have breathing difficulty or hyperventilation when unwell; and ask whether any of you have used a SpO2 Pulse Oximeter when you are unwell? These monitors are now cheap and accessible and very accurate.
They only give an indication of Oxygenation, but I have found my own SpO2 to be low during D-Lactic episodes.


The University of Tokyo has a similar non invasive method of detecting Lactic levels that could possibly be used to detect D-Lactic levels in ME/CFS;
https://onlinelibrary.wiley.com/doi/pdf/10.1002/ams2.348


Association between venous blood lactate levels and differences in quantitative capillary refill time Yasufumi Oi,1,2 Kosuke Sato,1,2 Ayako Nogaki,1,2 Mafumi Shinohara,1,2 Jun Matsumoto,1,2 Takeru Abe,2,3 and Naoto Morimura2,4 1 Emergency Care Department, Yokohama City University Hospital, 2 Department of Emergency medicine, Yokohama City University School of Medicine, 3 Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, and 4 Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Aim: Capillary refill time has been widely adopted for clinical assessment of the circulatory status of patients in emergency settings. We previously introduced quantitative capillary refill time and found a positive association between longer quantitative capillary refill time and higher lactate levels in the intensive care units, but not in the emergency department. In this study, we aimed to identify a quantitative and clinically applicable index of circulatory status (DAb) that can be measured with quantitative capillary refill time, then evaluated the linear association between this index and lactate levels in the emergency department.
CONCLUSION, IN this study, we introduced DAb, as assessed through Q-CRT, as an index of lactate levels to overcome the shortcomings of Q-CRT. We show that DAb is a feasible, non-invasive, and rapid assessment of lactate levels in emergency primary care settings. Future multicenter studies with a longitudinal design are needed to verify our findings.


There is no point in having Blood Gas or D-Lactic investigations unless you are very unwell; having breathing difficulty or hyperventilating (hyperventilation is the natural way that we cope with D-Lactate/raised Co2 and acidosis). The symptoms can fluctuate wildly; D-Lactic tests may not be accurate and the chances of most ME patients being given a D-Lactic or Blood Gas is close to 0.

I have just started using a cheap but accurate SpO2 Pulse Oximeter; and I can show drops in SpO2 when unwell. I was wondering if anyone else has used this when ill or during bad episodes of illness. It may be a way of proving that we are unwell and a way of monitoring illness. It would be easy to take photographs of the results with date and time to show how this is affecting you; and any relationship to Gut symptoms that you are experiencing.

I wanted to ask how many of us are aware of breathing difficulty when very unwell and how many suffer Hyperventilation?

After many years of breathing difficulty due to undiagnosed D-Lactic acidosis; I am very angry especially when I see that Simon Wessely has ''established the lack of relationship between hyperventilation and CFS'' and misguided ideology that ''he would not endlessly investigate for ineffective causes, using the analogy of a hit-and-run accident in which finding out the manufacturer or number plate of the car that hits you doesn't assist the doctor in trying to mend the injury, repeating that we are "in the business of rehabilitation" . You cannot rehabilitate acidosis, mitochondrial dysfunction or hyperventilation due to acidosis; these are not dysfunctional beliefs. You cannot establish a lack of relationship between hyperventilation and CFS; when you just have not found the relationship because you lack the necessary understanding of complex Gut issues that have only recently come to light as the tip of an iceberg. This thinking is beyond dysfunctional!

We need a signature for ME/CFS that is accurate, easy to access and dependable. It would be interesting to find out how many of us can measure a SpO2 drop when most unwell or hyperventilating.

D-Lactic ''Poisoning cannot be easily diagnosed because elaborative analytical methods are necessary to exactly distinguish the two isomers. Unfortunately, research on the mechanism of how D-lactic acid is produced, how to prevent complications, and how to diagnose poisoning is limited. Further research in this field is necessary.''

D-Lactic Acidosis: More Prevalent Than We Think?
med.virginia.edu › 2014/06 › Parrish-September-15


PDF
by R CASE · ‎2015 · ‎Cited by 4 · ‎Related articles
''A normal anion gap does not therefore definitively exclude D-lactic acidosis''.

 
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pattismith

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@pattismith There can be hidden data in anion gap. While your measure is in the normal range, it certainly is low end of normal and verging toward metabolic alkalosis. Your bicarbonate is higher than the normal 21-28. My bicarbonate was same as yours at 30. I'd be interested in your blood gases. I'd suspect, like me, you have respiratory acidosis, and your anion gap is perhaps showing compensatory metabolic alkalosis.
According to this graph, high bicarbonates can be from
-compensated respiratory acidosis
-metabolic alkalosis
-compensated metabolic alkalosis

1613891833667.png


I had an hyperventilation syndrome with Modafinil use, and the blood sample taken during the crisis showed bicarbonates at 30.5 and potassium at 5 (high)

The increased potassium is consistant with respiratory alkalosis (hyperventilation), but my bicarbonates should have dropped....that's weird....