Anion Gap Research Articles

Association between albumin-corrected anion gap and kidney function in individuals with hypertension – NHANES 2009–2016 cycle

Objectives Long-term uncontrolled hypertension increases the risk of kidney decompensation. This study aimed to explore the connection between albumin-corrected anion gap (ACAG) and kidney function in hypertensive patients. Methods This study utilized data from 1988 participants diagnosed with hypertension sourced from the NHANES database. Binary logistic regression analysis and subgroup analysis were utilized to investigate the relationship between ACAG and kidney function. The study employed restricted cubic spline (RCS) to assess the non-linear associations between ACAG and eGFR, as well as ACAG and ACR. Furthermore, mediation and moderation effect analyses were carried out, with blood pressure serving as the mediator and moderator, ACAG as the independent variable, and eGFR and ACR as the dependent variables. Finally, the study developed ACAG-based models for predicting kidney function decline. Results Higher ACAG is identified as an independent risk factor for eGFR < 60 mL/minute/1.73 m2 and ACR ≥ 30 mg/g. Results from RCS indicate a non-linear relationship between ACAG and eGFR, as well as between ACAG and ACR. The mediation effect analysis revealed that DBP mediated the relationship between ACAG and eGFR. Analysis on moderation effect demonstrated that SBP played a significant role in moderating the interaction between ACAG and ACR. Moreover, the models based on ACAG showed strong performance. Conclusions The levels of ACAG are found to be independently associated with both eGFR and ACR. Additionally, ACAG shows promise as a new and dependable biomarker for predicting the decline in kidney function in hypertensive patients.

Metabolic acidosis in patients with diabetes 2 undergoing cardiac surgery: The impact of SGLT2 inhibitor use: a retrospective cohort study.

Sodium-glucose cotransporter 2 inhibitors (SGLT2-i) lower blood sugar and reduce cardiovascular events and kidney failure. However, there have been increasing reports of euglycaemic diabetic ketoacidosis (eDKA) linked to SGLT2-i medicines. Investigating the association between SGLT2-i use and the incidence of metabolic acidosis in patients with type 2 diabetes undergoing cardiac surgery. A retrospective observational cohort study comprising 121 patients, with 38 in the SGLT2-i group and 83 in the control group. A 2-year period at Haukeland University Hospital, a tertiary regional hospital in Western Norway. Patients with type 2 diabetes undergoing cardiac surgery. Collection of clinical and laboratory data, including acid/base balance parameters, surgery details and SGLT2-i use. Base excess and anion gap measurements as indicators of ketosis development. A subgroup analysis in patients without renal failure (glomerular filtration rate > 60 ml min-1 m-2). Lower base excess levels and increased anion gaps were observed in the SGLT2-i group compared with controls at various time points postoperatively, with no significant differences in serum lactate levels.Twelve hours postoperatively, 41% of SGLT2-i patients without renal failure had a base excess -3 mmol l-1 or less after correction for serum lactate (indicating ketosis) compared with only 8% in the control group (P < 0.001). The anion gap was elevated in the SGLT2-i group compared to the control group at 12 h postoperatively (P = 0.018).Multivariable regression analysis identified SGLT2-i use as an independent factor associated with a lower base excess after correction for lactate levels (P < 0.001). Cessation of SGLT2-i medication did not correlate with the degree of acidosis. While taking SGLT2 inhibitors, diabetic patients undergoing heart surgery are at an increased risk of ketosis and possibly metabolic acidosis. This emphasises the importance of careful observation and effective treatment strategies within this group.

Construction of Survival Nomogram for Ventilator-Associated Pneumonia Patients: Based on MIMIC Database.

Objective: To construct and validate a predictive nomogram model for the survival of patients with ventilator-associated pneumonia (VAP) to enhance prediction of 28-day survival rate in critically ill patients with VAP. Methods: A total of 1,438 intensive care unit (ICU) patients with VAP were screened through Medical Information Mart for Intensive Care (MIMIC)-IV. On the basis of multi-variable Cox regression analysis data, nomogram performance in predicting survival status of patients with VAP at ICU admission for 7, 14, and 28 days was evaluated using the C-index and area under the curve (AUC). Calibration and decision curve analysis curves were generated to assess clinical value and effectiveness of model, and risk stratification was performed for patients with VAP. Result: Through stepwise regression screening of uni-variable and multi-variable Cox regression models, independent prognostic factors for predicting nomogram were determined, including age, race, body temperature, Sequential Organ Failure Assessment score, anion gap, bicarbonate concentration, partial pressure of carbon dioxide, mean corpuscular hemoglobin, and liver disease. The model had C-index values of 0.748 and 0.628 in the train and test sets, respectively. The receiver operating characteristic curve showed that nomogram had better performance in predicting 28-day survival status in the train set (AUC = 0.74), whereas it decreased in the test set (AUC = 0.66). Calibration and decision curve analysis curve results suggested that nomogram had favorable predictive performance and clinical efficacy. Kaplan-Meier curves showed significant differences in survival between low, medium, and high-risk groups in the total set and training set (log-rank p < 0.05), further validating the effectiveness of the model. Conclusion: The VAP patient admission ICU 7, 14, and 28-day survival prediction nomogram was constructed, contributing to risk stratification and decision-making for such patients. The model is expected to play a positive role in supporting personalized treatment and management of VAP.

Combined effect of anion gap and red cell distribution width on the risk of acute kidney injury after cardiac surgery

BackgroundThis study was to analyze the roles of red blood cell distribution width (RDW), anion gap (AG) levels and their combined effects on the risk of acute kidney injury (AKI) following cardiac surgery.MethodsThis cohort study extracted the data of 1951 participants aged ≥ 18 years with the assessment of AKI after cardiac surgery during ICU stay from MIMIC-IV database between 2008 and 2019. Receiver operator characteristic (ROC) curve was used to determine the optimal cut-off value AG and RDW. The associations between AG, RDW, and the combined effects of AG and effects were evaluated via univariable and multivariable Logistic models. Odds ratio (OR) with 95% confidence interval (CI) were imputed.ResultsAmong all the participants, 831 participants had AKI, and 1120 did not have AKI. ROC curves revealed that the optimum cut of points of AG and RDW were 12.75 mmol/L, and 13.65%, respectively. Increased risk of AKI was found in patients after cardiac surgery with AG > 12.75 mmol/L (OR = 1.44, 95%CI 1.15–1.80) or RDW > 13.65% group (OR = 1.23, 95%CI 1.01–1.50). In comparison to subjects with AG ≤ 12.75 mmol/L and RDW ≤ 13.65%, AG > 12.75 mmol/L and RDW ≤ 13.65% (OR = 1.42, 95%CI 1.07–1.89), and AG > 12.75 mmol/L and RDW > 13.65% (OR = 1.75, 95%CI 1.24–2.47) were associated with increased odds of AKI in patients after cardiac surgery.ConclusionsAG and RDW had combined effects on risk of AKI in patients after cardiac surgery, which might offer an insight for the management of patients after cardiac surgery.

Association between serum anion gap and 28-day mortality in critically ill patients with infective endocarditis: a retrospective cohort study from MIMIC IV database

BackgroundThe relationship between serum anion gap (AG) and 28-day mortality in critically ill patients with infective endocarditis is currently not well established.ObjectiveThis study aims to investigate the impact of serum AG on 28-day mortality in critically ill patients with infective endocarditis.MethodsA retrospective cohort study was conducted involving 449 participants diagnosed with infective endocarditis and admitted to intensive care units (ICU). Vital signs, laboratory parameters and comorbidity were collected for all participants to analyze the association between anion gap levels and 28-day mortality.ResultsA total of 449 critically ill patients with infective endocarditis (IE) were included in the study. The mean age was 57 years, and 64% were male. The overall 28-day mortality rate was 20%. A greater AG on admission were significantly associated with increased 28-day mortality in unadjusted analysis (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.09–1.18; p < 0.001). After adjusting for all confounders, the association remained significant (adjusted HR 1.07; 95% CI 1.02–1.13; p = 0.003). When AG was converted into categorial variables (quartiles), the risk of 28-day mortality in the greatest Q4 group was significantly higher compared with that in the lowest Q1 group (model 4: HR = 2.62, 95%CI: 1.17–5.83, p = 0.019). Subgroup analysis showed consistent results across different groups.ConclusionA greater AG on admission were independently associated with increased 28-day mortality in critically ill patients with IE. These findings suggest that the AG can serve as a prognostic marker in this population, aiding in risk stratification and guiding clinical management.

The optimal dietary sodium and chloride level for broiler chicks fed a corn-soybean meal diet between 1 and 21 days of age.

The experiment was conducted to estimate the ideal dietary sodium (Na) and chloride (Cl) level for broilers during d 1 to 21 using a corn-soybean meal diet under a dietary Na:Cl ratio of 1:1. A total of 490 one-d-old Arbor Acres male broilers were randomly allotted by bodyweight to 1 of 7 treatments in a completely randomized design. Each treatment consisted of 7 replicate cages with 10 chicks per cage. Broilers were fed a Na and Cl-unsupplemented corn-soybean meal basal diet (control, containing 0.02% Na and 0.08% Cl) and the Na and Cl-supplemented basal diets containing 0.14%, 0.20%, 0.26%, 0.32%, 0.38% and 0.44% Na and Cl levels, respectively for 21 d. The results indicated that average daily gain, average daily feed intake, blood partial pressure of CO2 and concentrations of HCO3-, total CO2, Na+, Cl-, base excess and anion gap, tibial ash and ash Na contents of broilers were affected (P < 0.001) by dietary Na and Cl level, and increased linearly (P < 0.001) and quadratically (P < 0.001) with increasing Na and Cl levels. Feed/gain ratio, mortality, blood K+ concentration, serum osmotic pressure and K+, glucose and uric acid concentrations as well as heart, liver and kidney indices of broilers were affected (P < 0.01) by dietary Na and Cl level, and decreased linearly (P < 0.001) and quadratically (P < 0.001) with increasing Na and Cl levels. The estimates of dietary optimal Na and Cl levels were 0.07%-0.16% according to the best fitted broken-line or asymptotic models (P < 0.001) of the above sensitive indicators. Therefore, the optimal dietary Na and Cl level was suggested to be 0.16% to support all of the above Na and Cl metabolic requirements of broilers fed the corn-soybean meal diet during d 1 to 21, which is lower than the recommendation at 0.20% by the Chinese Feeding Standard of Chicken (2004).

Factors affecting time to recovery from diabetic ketoacidosis in adult diabetic patients in Alexandria Main University Hospital

BackgroundDiabetic ketoacidosis (DKA) is a life-threatening condition as a complication of diabetes and represents a significant healthcare global burden. The current study goal was to determine factors affecting time to recovery from DKA in Alexandria Main University Hospital.Patients and methodsOne hundred fifty patients who had been admitted with DKA were included in this study. All patients were managed with hospitalization for IV fluids, continuous intravenous insulin infusion, electrolyte correction, as well as detection and treatment of the predisposing factor until the full resolution of DKA.ResultsMales contributed to 58.7% of the total patients in this study with a mean age of 32.16 ± 15.06 years. DKA mean time of resolution was 18.76 ± 14.07 h. The majority of patients were with T1DM (86%), while T2DM were 14%. Missed insulin dose was the leading precipitating factor (60.7%) followed by infections (38.7%). There was a statistically significant relationship between DKA resolution time with age, time of presentation, type of diabetes, initial pH, initial serum K+ level, initial HCO3− level, initial anion gap, initial base excess, and initial RBS (p value < 0.001).ConclusionDelayed time of resolution from DKA was associated with initial lower pH, initial lower HCO3− level, initial lower base excess level, initial higher anion gap level, type 2 diabetes mellitus, patients on pre-mixed insulin regimen, old patients, delayed time for seeking medical care, and abnormal serum K+ level.

Association between serum calcium and in-hospital mortality in intensive care unit patients with cerebral infarction: a cohort study

BackgroundThe relationship between serum calcium levels and the prognosis of cerebral infarction remains controversial.PurposeThis study aims to investigate the correlation between serum calcium levels and in-hospital mortality in critically ill patients with ischemic stroke admitted to the intensive care unit (ICU).MethodsA retrospective cohort study was conducted using data from the MIMIC-IV database. Demographic and clinical data of all participants were collected including gender, age, hypertension, diabetes, myocardial infarction, heart failure, chronic obstructive pulmonary disease, hemoglobin, potassium, sodium, anion gap, platelets, white blood cells, glucose, creatinine, Glasgow coma score (GCS), IV-tPA administration (rt-PA), and mechanical thrombectomy (MT). The outcome measure was in-hospital death. Multivariable-adjusted logistic regression analysis, curve fitting, interaction analysis, and threshold effect analysis were employed to evaluate the relationship between serum calcium levels and in-hospital mortality among ICU patients with cerebral infarction.ResultsA total of 2,680 critically ill patients with cerebral infarction were enrolled, with a mean serum calcium level of 8.6 ± 0.8 mg/dL. The overall in-hospital mortality rate was 19.5%, where Group 1 (serum calcium &amp;lt; 8.0 mg/dL) had a mortality rate of 27.7%, Group 2 (serum calcium 8–9 mg/dL) had a rate of 19.8%, and Group 3 (serum calcium ≥ 9 mg/dL) had a rate of 13.9%. There was a non-linear, S-shaped relationship between serum calcium levels and in-hospital mortality. Serum calcium levels within the range of 7.70–9.50 mg/dL were found to be independently associated with increased in-hospital mortality in ICU patients with cerebral infarction. No significant interactions were detected in subgroup analyses, and the results of sensitivity analyses remained stable.ConclusionSerum calcium levels are independently associated with in-hospital mortality in critically ill patients with cerebral infarction in the ICU setting. Within the range of 7.70–9.50 mg/dL, lower serum calcium levels increase the risk of in-hospital death among these patients, emphasizing the importance of close monitoring by ICU physicians.

The association between anion gap and length of stay in patients undergoing hip fracture surgery: data from the MIMIC-IV database

ObjectiveTo explore the relationship between anion gap (AG) and length of stay (LOS) in patients undergoing hip fracture surgery.MethodsClinical data of patients diagnosed with hip fracture and undergoing surgery were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Logistic regression analysis by adjusting different covariables and threshold effect analysis were used to analyze the relationship between AG and LOS. Subgroup analysis and interaction test were also performed to detect their relationship. Receiver Operating Characteristic (ROC) analysis was performed to identify the prediction performance and cutoff value of AG.Kaplan-Meier (KM) survival analysis was used to explore the influence of AG on overall survival.ResultsA total of 1508 patients were enrolled and the median LOS was 4.9 days. The correlation between AG and LOS > 7 days was observed among 3 regression models when regarding AG as continuous variables (all OR > 1, all P < 0.05). After stratifying samples with AG quartiles, their relationship was only presented in the Q4 group both in model 1 and model 2 (all P < 0.001). The risk of LOS > 7 days gradually increased with increasing AG quartiles (all P for trend < 0.05). Further, threshold effect analysis found that their association was mainly observed when AG ≥ 14 mEq/L (OR = 1.122, P < 0.001). Subgroup analysis showed that their correlation was not influenced by sex, age, BMI, ethnicity, classification of fracture, therapeutic method, CHD, hypertension, osteoporosis, diabetes and admitted to the ICU (all P for interaction > 0.05). ROC analysis identified 14.5 as the cutoff value of AG for predicted LOS > 7 days. Survival analysis found that patients in the AG < 14.5 group had better overall survival.ConclusionIn patients undergoing hip fracture surgery, the AG was positively correlated with LOS, and 14.5 mEq/L AG was the cutoff value for predicting LOS > 7 days. The cutoff value can favorably distinguish the survival difference of patients.

Euglycemic Diabetic Ketoacidosis Presenting as Chest Pain and Vomiting in a Patient taking SGLT-2 inhibitor

Empagliflozin-induced Euglycemic Diabetic Ketoacidosis (EDKA) is a life-threatening metabolic emergency of Diabetes Mellitus. It is characterized by metabolic acidosis (i.e., pH &lt;7.3 and Serum bicarbonate &lt;15mEq/dl) with an increased anion gap, ketonemia and relatively normal serum glucose level. EDKA resembles Diabetic Keto Acidosis (DKA) but does not exhibit the typical high blood sugar levels. In EDKA, blood glucose is usually below 200 mg/dL. This condition is a diagnostic challenge as euglycemia masks the underlying diabetic ketoacidosis. Here we present a case of Empagliflozin-induced Euglycemic Diabetic Ketoacidosis presented with palpitation and several episodes of vomiting. The aim of this article is to create awareness among clinicians to consider this diagnosis in the differential, especially in the patients taking SGLT-2 inhibitors. Bangladesh Crit Care J September 2024; 12 (2): 172-174

Effect of Pre-Analytical Line Settings on Artefactually Elevated Anion Gap Results

Abstract Introduction When the core lab at a large tertiary care hospital introduced an automated laboratory system from a major manufacturer, the automated line aliquoted patient serum into open cups for all chemistry testing. It was subsequently discovered that if sample testing was delayed, electrolyte abnormalities could be introduced from evaporation, resulting in an increased anion gap (presumably due to a loss of bicarbonate with evaporation of carbon dioxide). To address this issue, the core lab changed the sample processing protocol in April 2023 from an open cup system to testing primary tubes on the analyzers. The purpose of this study was to evaluate the impact of switching to a primary tube testing system on artefactually elevated anion gap results. Methods Equivalent ten-week blocks of anion gap, creatinine and sample turnaround time (from receipt on the line to analyzer perform time) results from pre- to post-primary tube conversion were collected from the laboratory information system. Data from weekend testing and from repeat samples from the same patient were excluded. Data was cleaned and analyzed using R. Results Multivariable linear regression showed that when adjusted for the turnaround time and creatinine result, the open cup system was significantly associated (p&amp;lt;0.0001) with a 0.95 [95% CI 0.69-1.21] increase in anion gap. There was a positive relationship between turnaround time and anion gap, with a slope of 0.017 (i.e., a 0.017 increase in anion gap per minute delay; p&amp;lt;0.0001). Overall, the proportion of abnormal results (defined as anion gap &amp;gt;=16) decreased from 26% to 10% after switching to a primary tube testing system. Furthermore, there was an association between the times of day in which the lines were overloaded with specimens, turnaround time, and an increase in abnormal anion gap results. Overall, the mean anion gap decreased by 1 with a turnaround time of one hour and 2 after two hours by switching to the primary tube system. This trend in anion gap was largely driven by a corresponding decrease in bicarbonate. Sodium and chloride levels did not show any relationship with turnaround time. Conclusions Using an open cup system for electrolyte testing can cause spuriously elevated anion gap levels, especially with testing delays. Switching to a primary tube testing system largely resolved the issue; however, the data still showed a weakly positive relationship between turnaround time and anion gap for the primary tube testing system, so additional work is needed to identify potential causes of this relationship.

Mind the Gap: Influence of Monoclonal Immunoglobulin on Anion Gap in Multiple Myeloma

Abstract Background Multiple myeloma (MM) is a plasma cell disorder in which anion gap and sodium measurement are critically influenced by the presence of abnormal protein concentrations. This study investigates the relationship between anion gap, pseudohyponatremia, and monoclonal immunoglobulin levels (IgG, IgA, IgM), particularly the common IgG. Focusing on the clinical implications of these laboratory results. Methods We retrospectively analyzed data from 136 patients diagnosed with MM, focusing on anion gap values, monoclonal immunoglobulin levels, and sodium levels. The patients were categorized based on their anion gap values (&amp;lt;8) into five groups (anion gap=3, 4, 5, 6, and 7). Monoclonal immunoglobulin levels were standardized to the same units as the anion gap for direct comparison. Additionally, we investigated the pseudohyponatremia by examining sodium levels in these patients. Results Among the 136 MM patients, 70 patients’ anion gap were lower than 8. A negative correlation between MM monoclonal immunoglobulins and anion gap values were observed. The anion gap decreased from 7 to 3 as the IgG average levels ranged increasing from 1755 mg/dL to 2655 mg/dL (RI 610-1616 mg/dL). Similarly, the anion gap decreased from 6 to 3 as the IgM average levels ranged increasing from 1170 mg/dL to 2880 mg/dL (RI 35-242 mg/dL). Additionally, a number of low sodium levels (&amp;lt;136 mmol/L) was observed in each group. Conclusion Our study highlights the negative impact of MM monoclonal immunoglobulins, particularly IgG and IgM, on the anion gap. Both laboratory and clinical personnel should be aware of these phenomena, might prevent unnecessary diagnosis, streamlining patient management and avoiding potential mismanagement.

A rare and underestimated cause of anion gap metabolic acidosis in a pediatric patient

Abstract Recognized causes of anion gap metabolic acidosis include methanol, uremia, diabetic ketoacidosis, propylene glycol, isoniazid, iron, lactic acidosis, ethylene glycol, and salicylates, which is taught as the mnemonic, MUDPILES. While this mnemonic can be a useful learning tool, it is important to consider other, atypical causes. Here, we present the case of a 9-year-old male patient with a complex medical history, including trisomy 21 and Lennox-Gastaut syndrome who presented to the emergency department (ED) in hypotensive shock. Upon admission, he was noted to have a distended abdomen, evidence of acute pancreatitis and possible sepsis. Of note, his initial labs revealed an anion gap of 30.1 mmol/L, a whole blood lactate of 4.4 mmol/L, a pH of 7.2, and a normal pCO2, indicting an anion gap metabolic acidosis. Importantly, methanol, ethylene glycol, ketones, and salicylates were not detected, and renal function was normal. However, he did have an extensive medication history, including several antiepileptic drugs (AEDs). Over the coming weeks, he recovered from the acute pancreatitis, but developed fluid overload, electrolyte derangements (hypernatremia and hypokalemia), a worsening metabolic acidosis with an anion gap up to 54.6 mmol/L, and hyperammonemia (plasma NH3 of 232 μmol/L). At this point, the metabolism team was contacted for concerns regarding the rising ammonia levels, which subsequently responded to a combination of lactulose and Rifaximin. An inborn error of metabolism (IEM) was considered, and plasma amino acid analysis was performed (Waters Acquity MassTrak AAA solution) but was not diagnostic. Notably, the patient developed a significantly elevated gamma glutamyl transpeptidase (GGT) up to 4088 U/L, suggesting glutathione depletion, however, transaminases and alkaline phosphatase were normal. The laboratory was contacted by the metabolism providers for other possible causes of metabolic acidosis and it was suggested that the patient undergo urine organic acid testing. Urine specimens were analyzed using gas chromatography/mass spectrometry (GC/MS) (Aligent system). The results were notable for marked excretion of pyroglutamic acid (5-oxoproline), which is typically associated with acetaminophen, however, the patient’s acetaminophen levels were less than 5 μg/mL, indicating another, atypical cause of increased pyroglutamic acid. In this case, vigabatrin, an anticonvulsant known to cause glutathione depletion and secondary pyroglutamic aciduria was suspected, and subsequently withdrawn. The patient was also started on a trial of N-acetylcysteine (NAC) to replenish glutathione, which resolved the pyroglutamic aciduria and anion gap, and corrected the metabolic acidosis. This case highlights the importance of recognizing pyroglutamic acid as a rare cause of anion gap metabolic acidosis, even in the setting of normal acetaminophen levels, and the importance of organic acid testing in the work-up of such patients. Wider use of the mnemonic GOLD MARK, where the “O” stands for oxoproline, may help in the differential diagnosis of anion gap metabolic acidosis.

Urgent-Start Peritoneal Dialysis in Metformin-Associated Lactic Acidosis: A Critical Alternative When Immediate Hemodialysis is Unavailable.

Introduction Intermittent hemodialysis (IHD) is a preferable renal replacement therapy (RRT) option in metformin-associated lactic acidosis (MALA) due to rapid correct metabolic acidosis. However, IHD might not be started immediately. Immediate urgent-start peritoneal dialysis (iUSPD) is used as a life-saving dialysis option and then followed by IHD. The outcomes of iUSPD were compared with other extracorporeal dialysis in MALA. Methods In two tertiary hospitals in Thailand, the outcomes of patients with MALA who had received three different RRT modalities (iUSPD followed by IHD, IHD, and continuous renal replacement therapy [CRRT]) from January 2015 to December 2019 were compared. The primary outcome was 30-day mortality. The secondary outcomes were door-to-dialysis time and 90-day RRT dependence. Results 180 MALA cases that required dialysis were included (20 iUSPD, 120 IHD, and 40 CRRT). Their mean age was 64 years. Most of the patients had severe metabolic acidosis (mean pH 6.91, HCO3 6 mmol/L, and anion gap 40 mmol/L) and were critically ill. The 30-day mortality was 30% in iUSPD, 9.2% in IHD, and 32.5% in CRRT, p = 0.001). The mortality risk in the iUSPD group was not significantly different from those of the IHD and CRRT groups (adjusted HR 2.5, 95% CI 0.65-9.6 and adjusted HR 0.75, 95% CI 0.2-2.78, respectively). All dialysis modalities had comparable 90-day dialysis dependence. iUSPD exhibited the shortest door-to-dialysis time. Conclusion In MALA, iUSPD followed by IHD might be a viable RRT option to save patient lives if no other dialysis option are available.

Association between delta anion gap/delta bicarbonate and outcome of surgical patients admitted to intensive care unit

BackgroundPatients undergoing high-risk surgeries with acid-based disorders are associated with poor outcomes. The screening of mixed acid-based metabolic disorders by calculating delta anion gap (AG)/delta bicarbonate (Bic) has a clinically relevant role in patients with high AG metabolic acidosis (MA), however its utility in individuals facing high-risk surgical procedures remains unclear.ObjectiveCharacterize metabolic acidosis using delta-AG/delta-Bic and its associations in patients undergoing high-risk surgeries with possible outcome-related complications.DesignProspective observational multicentric study.SettingThree tertiary hospitals in Brazil.PatientsPatients undergoing high-risk surgeries, aged 18 years or older, requiring postoperative critical care.Main outcome measuresPatients undergoing high-risk surgeries monitored during the postoperative phase across three distinct intensive care units (ICUs), with assessment encompassing laboratory analyses upon admission and 24 h thereafter. Patients with MA and with elevated AG within 24 h were separated into 3 subgroups: [G1 – delta-AG/delta-Bic < 1.0] MA associated with hyperchloremia; [G2 – delta-AG/delta-Bic between 1.0 and 1.6] MA and no mixed disorders; and [G3 – delta-AG/delta-Bic > 1.6] MA associated with alkalosis. Primary endpoint was 30-day mortality. The secondary endpoints were cardiovascular, respiratory, renal, neurological, coagulation and infective complications.ResultsFrom the 621 surgical patients admitted to ICU, 421 (51.7%) had any type of acidosis. After 24 h, 140 patients remained with MA with elevated AG (G1: 101, G2: 18, and G3: 21). When compared to patients from subgroups 1 and 3, the subgroup with no mixed disorders 2 showed higher 30-day mortality (adjusted HR = 3.72; 95% CI 1.11–12.89, p = 0.001), cardiovascular complications (p = 0.001), ICU mortality (p = 0.03) and sum of all complications during the ICU period (p = 0.021).ConclusionIn the postoperative time, patients with metabolic acidosis and no mixed disorders present higher ICU-Mortality and higher cardiovascular postoperative complications when compared with patients with combined hyperchloremia or alkalosis. Delta-AG/delta-Bic can be a useful tool to evaluate major clinical outcomes in this population.

Electrocardiographic Changes, Mortality, and Late Period Findings in Methyl Alcohol Poisoning

Background: Methyl alcohol poisoning (MAP) is a common commercial compound that can lead to significant morbidity and mortality when exposed to high levels. This study aims to describe MAP-related electrocardiography (ECG) changes and post-acute late complications. Materials and Methods: The study was conducted through a retrospective data review between 2017 and 2023. Patient data were recorded, including demographic information, medication use, and laboratory results. Twelve-lead ECG recordings were evaluated and the results were recorded. The cases included in the study were grouped according to QTc distance, ECG findings, late-term complications, treatment status, and mortality. Results: The mean age of all cases included in the study (n = 227) was 43.23 ± 11.11 years, 8 (3.5%) cases were female, and the age distribution was between 19 and 68 years (p = 0.792). The age distribution of QTc groups was not significant (p = 0.792). The mean QTc distance was 442.7 ± 60.1 ms in all cases (n = 227) and 514.08 ± 5.45 ms in cases with mortality (n = 49) (p &lt; 0.001). The mean time to application of the patients to the hospital (n = 227) was 19.1 ± 4.61 h, and blood sugar was 130.7 ± 32.09 mg/dL (p &lt; 0.001). In addition, the mean pH of the cases (n = 227) was 7.14 ± 0.2, bicarbonate was 17.17 ± 4.86 mmol/L, the base deficit was −6.21 ± 3.18 mmol/L, the anion gap was 19.36 ± 7.31 mmol/L, and lactate was 4.82 ± 2.45 mmol/L (p &lt; 0.001). Mortality occurred in 49 (21.6%) of the patients, and all of them were in-hospital deaths. In all cases where mortality occurred, pH was below 6.93 ± 0.22 and severe acidosis was directly related to death. MAP, sinus tachycardia in 31 (13.7%) cases, bradycardia in 8 (3.5%), atrial fibrillation in 5 (2.2%), accelerated idioventricular rhythm in 3 (1.3%), and 11 (4.8%), left bundle branch block, and right bundle branch block were detected in 22 (9.7%). All of these ECG findings were newly developed conditions with no previous history. In the 6-month follow-up after discharge, 4 (1.8%) of the cases developed neurological deficit, 15 (6.6%) had acute coronary syndrome and severe heart failure, 23 (10.1%) had permanent blindness, 6 (2.7%) had renal failure, and 6 (2.7%) had pancreatitis. Conclusion: Methyl alcohol poisoning can cause various ECG changes; sinus tachycardia, nonspecific changes, and QTc prolongation are the most common findings. These changes are more pronounced in cases of severe acidosis. Patients should be warned of late signs of MAP.

12469 Impact Of Covid-19 Infection On Diabetic Ketoacidosis Severity And Outcomes In Adult Population- A Retrospective Observational Study

Abstract Disclosure: E.M. Niedzialkowska: None. K. Childers: None. L. Qu: None. L. Misra: None. M.R. Brennan: Consulting Fee; Self; Insulet Corporation, Bayer, Inc., Novo Nordisk. Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM) that can be precipitated by SARS-CoV2 infection. We analyzed clinical and demographic characteristics of patients admitted with DKA to investigate if SARS-CoV2 infection affects DKA severity on admission and outcomes. Methods: We conducted a retrospective cohort study that included adult patients admitted with a diagnosis of DKA between March 1, 2020, and March 1, 2023. Patients' demographic data including age, sex, race, ethnicity, laboratory test results on admission, ICU admissions and length of hospital stay (LOS) were compared. Patient characteristics and outcomes of interest were stratified by COVID-19 test results and compared using the Kruskal-Wallis test for continuous variables and Fisher’s exact test for categorical variables. DKA severity was classified based on HCO3 values: mild 15-18 mEq/L, moderate 10-14 mEq/L, severe &amp;lt;10 mEq/L. Results: The study included 902 patients, of which 734 tested negative (COVID-) and 168 tested positive (COVID+) for SARS-CoV2. The mean age was significantly higher (54.09) in COVID-19+ group compared to COVID-19- group (48.25) (p&amp;lt;0.001). The cohort included 49.1% females, 51.7% Whites, 43.3% Blacks, 89.8% Non-Hispanic/Latino, 2.7% Hispanic/Latino. We did not find statistically significant differences in sex (p= 0.608), race (p =0.277), ethnicity (p=0.072) anion gap (p=0.783), glucose (p=0.140), hemoglobin a1c (ha1c) values on admission (p=0.876) and ICU admissions (p=0.266) between both groups. The majority (55.3%) of the patients presented with severe DKA, followed by moderate DKA in 26.6% and mild disease in 18.1% of patients without statistically significant differences between groups (p= 0.128). The mean LOS in COVID + group (11.94 days) was longer than COVID- (6.85) group (p&amp;lt;0.001). Mean venous pH was significantly lower in COVID-19- (7.14) compared to COVID+ (7.17) group (p= 0.016). Betahydroxybutyrate (BHB) levels on admission were higher in COVID- group (7.98 mmol/L, N 0.02-0.27 mmol/L) compared to COVID + (7.10mmol/L) cohort. Conclusion: Patients diagnosed with COVID-19 and DKA on admission did not present with more severe disease compared to patients that tested negative. COVID+ patients were older (54.09 vs 48.2) and had significantly longer LOS (11.94 vs 6.85 days). We did not identify statistically significant differences between race, ethnicity, sex, glucose, anion gap, Ha1c on admission and ICU admission rate. BHB levels on admission were higher in patients that tested negative. Interestingly, mean pH was higher in COVID-19 positive group possibly due to respiratory disorders. Presentation: 6/1/2024

6541 Recurrent Euglycemic Diabetic Ketoacidosis And Myonecrosis In A Patient Previously Thought To Have Type 2 Diabetes Mellitus

Abstract Disclosure: K. Haridas: None. M.M. McConnell : None. Introduction: Euglycemic diabetic ketoacidosis (DKA) is a well-recognized complication with the use of sodium linked cotransport of glucose-2 (SGLT2) inhibitors. Diabetic myonecrosis is a rare complication of diabetes mellitus caused by spontaneous death of muscle due to microvascular ischemia. Clinical Case: A 48-year-old male diagnosed with Type 2 Diabetes Mellitus with HbA1c 11.3%, treated with Empagliflozin and basal-bolus insulin was admitted to the hospital with left thigh pain and anorexia. Physical examination was notable for BMI of 19kg/m2 and left lateral thigh induration. Laboratory evaluation revealed venous pH 7.1, bicarbonate 10mmol/L (20-30), anion gap 32mmol/L(8-12), glucose 168mg/dl (65-99), ESR 67mm/h (&amp;lt;=12), Creatinine Kinase 31 U/L (63-473), glucosuria (4+) and ketonuria (4+). He was diagnosed with euglycemic DKA due to SGLT2 inhibitor. He was also diagnosed with Type 1 Diabetes Mellitus (T1DM) based on undetectable C-peptide and GAD antibody titer 64.3IU/ml(&amp;lt;5). MRI of the left thigh revealed an area of diabetic myonecrosis, measuring 11cm. He was treated with continuous insulin infusion. On hospital day 3, after resolution of the anion gap metabolic acidosis, transition was made to basal-bolus insulin. On hospital day 5, recurrent euglycemic DKA was diagnosed with bicarbonate 15mmol/L, anion gap 18mmol/L, beta-hydroxybutyrate 49.6mg/dl (&amp;lt;=3mg/dl), glucose 185mg/dl, glucosuria (4+) and ketonuria (4+). Continuous insulin infusion was restarted. On hospital day 8, transition was made to subcutaneous insulin. Diabetic myonecrosis was initially managed conservatively with analgesics, aspirin, and physical therapy. Due to worsening leukocytosis on hospital day 13, Ceftriaxone was started and surgical debridement was performed, revealing a loculated abscess within necrotic muscle. Empagliflozin was discontinued at discharge. Discussion: The risk of euglycemic DKA with SGLT2i use is increased in patients with T1DM and decreased oral intake, and insults like trauma or surgery as seen in this patient. Although the half-life of empagliflozin is 12 to 14 hours, there have been case reports of persistent or recurrent euglycemic DKA for 7-12 days from the time of last dose. The continued glucosuria and ketonuria in this patient with serum glucose levels below the renal threshold confirmed the recurrence. Diabetic myonecrosis usually affects the muscles of the proximal lower extremities and is seen in patients with poorly controlled diabetes with microvascular complications, between one and two decades after diagnosis, as in this patient. Conclusion: A high index of suspicion for recurrent euglycemic DKA must be maintained in patients who have new or persistent high anion gap metabolic acidosis until 2 weeks from last dose of SGLT2 inhibitor. Diabetic myonecrosis, especially if complicated by abscess formation, may require surgical intervention. Presentation: 6/1/2024

8725 Subcutaneous Compared With Intravenous Insulin Protocol For Management Of DKA: A Longitudinal Experience In A Single Center

Abstract Disclosure: S. Avula: None. M. Salim: None. E. Wetherbee: None. C. Wenner: None. A. Gravely: None. A.D. Westanmo: None. N.G. Ercan-Fang: None. Background: Diabetic ketoacidosis (DKA) is a critical condition requiring immediate medical attention to prevent severe health complications and even death. Typically, patients are placed under the care of the intensive care unit (ICU) to ensure close supervision. With implementation of effective subcutaneous insulin protocol (SIP), patients can be safely managed outside of ICU without any significant change in mortality or morbidity, potentially decreasing financial burden of costly ICU stay. Aim: To review and compare the experience with subcutaneous and intravenous insulin protocols for management of DKA at Minneapolis Veterans Affairs Health Care System (MVAHCS). Methods: We conducted a retrospective chart review of patients who were admitted with DKA at MVAHCS from 2013 - 2023 and were treated with either I.V insulin or SIP. Inclusion criteria: Adults (age &amp;gt;/=18 years) admitted with DKA between 2013 and 2023. Exclusion criteria: Non availability of VBG/ABG and patients who were not treated initially at MVAHCS. Statistical analysis used was basic descriptive analysis, Pearson’s Chi-Square and Two sample T test. Results: Majority of patients included were males: 57 (96.61%) and 16 (88.89) in SIP and I.V insulin, respectively. Racial distribution of patients was skewed towards a white population: Total of 57 (74.03%) were white, 12 (15.58%) were African American (AA). A significant majority of white patients 47 (79.66%) were on SIP, while 10 (55.56%) were on I.V insulin. Mean age of SIP and I.V insulin study populations were 58.9 (SD 16.21) and 59.2 years (SD 12.23), respectively. Baseline mean pH of the SIP and I.V insulin study populations were 7.27 (SD 0.08) and 7.13 (0.13), respectively. Mean bicarb for SIP was 14.9 mEq/L (SD 4.60) and I.V Insulin was 10.1 mEq/L ( SD 4.57). Mean time for anion gap (AG) closure among patients on SIP was modestly higher at 19.7 hours (SD 15.3) when compared to that on I.V insulin of 17.1 hours (SD 12.4) but the difference did not reach statistical significance. Similarly, 55.6% (n=10) of patients on I.V insulin and 58.6% (n=34) of those on SIP had anion gap closure of &amp;gt;/= 12 hours (p = 0.8187). When adjusted for baseline pH and bicarbonate, 46% of patients in the I.V insulin group had AG closure &amp;gt;=12 hours, whereas 67% of those in the SIP group had AG closure &amp;gt;=12 hours with total difference of 21% (p= 0.2098). Conclusion: Our results demonstrate that SIP can be safely implemented outside of the ICU setting. Compared with SIP, baseline pH was slightly less in the IV group (our protocol directs sicker patients with lower baseline pH towards the I.V insulin rather than SIP), however, AG closure time was similar between the two groups even after performing multiple regression analysis where we adjusted for baseline differences between two treatment groups in pH, bicarbonate, AG. These results indicate that SIP could be safe and potentially cost saving alternative for DKA management. Presentation: 6/3/2024

8226 A Diagnostic Challenge: Factitious Hypobicarbonatemia in Severe Hypertriglyceridemia

Abstract Disclosure: U. Rafat: None. S. Azmat: None. M. Siddiqui: None. R. Alshantti: None. D. Kircheva: None. V. Trendafilova: None. Background: Serum CO2 levels measured by a chemistry analyzer usually correlate with calculated bicarbonate levels on an ABG. There are some instances however, when this is not the case. Severe hypertriglyceridemia can cause serum bicarbonate levels to appear falsely low on metabolic panel. Clinical Case: A 48-year-old man was referred to Endocrinology Clinic for evaluation of hypogonadism and severe hypertriglyceridemia. Routine labs revealed a plasma CO2 of 11 mmol/L (20-31). Na was 133 mmol/L (136-145), K was 4.4 mmol/L (3.5-4.7), Chloride was 101 mmol/L (98-109) and anion gap was 25 (8-20) measured using a Siemens Vista enzymatic chemistry analyzer. His triglycerides were &amp;gt; 1100 mg/dL (0-150), above upper detection limits of the analyzer. The patient reported fatigue and mild abdominal pain. He was admitted to the hospital for further evaluation. His lipase was 41 U/L (12-73), lactic acid 1.2 mmol/L (0.50-2.20). ABG showed pH of 7.41, HCO3 of 26.6 mmol/L (22-29), and anion gap of 7 (10-20). The patient was well-appearing with normal vital signs and normal physical exam. He was made NPO and started on pravastatin, fenofibrate and fish oil. Once his triglycerides were &amp;lt; 1000 mg/dL, he was started on a very low-fat, low-carbohydrate diet. The CO2 level on BMP normalized on day 3 of hospitalization, when triglycerides measured 1010 mg/dL. No other treatment was given for the low CO2 levels. It does not appear that other lab indices were significantly affected by the hypertriglyceridemia. Review of Literature: A BMP measures serum total carbon dioxide using a chemistry analyzer using either an enzymatic/spectro-photometric method, or an electrode-based method; an ABG sample calculates plasma bicarbonate with the Henderson-Hasselbach equation, using the pH and partial pressure of pCO2 in the sample. Enzymatic analyzers measure CO2 using spectrophotometry and decrease in light absorbance is proportional to the sample’s CO2 levels. It is postulated that severely high triglycerides can interfere with this reaction and cause spuriously low CO2 levels, a phenomenon called pseudohypobicarbonatemia. One proposed mechanism for interference with the enzymatic assay method is turbidity causing a falsely low measured CO2 level. Verghese et al found that the severity of the CO2 measurement error positively correlates with the severity of triglyceride elevation. Conclusion: Awareness of the phenomenon of hypertriglyceridemia-induced pseudohypobicarbonatemia can prevent misdiagnosis or delays in diagnosis, as well as unwarranted testing and treatment. Presentation: 6/3/2024