Metabolic acidosis differential diagnosis: Difference between revisions
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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Metabolic_acidosis]] | |||
{{CMG}}; {{AE}} {{SSH}} | {{CMG}}; {{AE}} {{SSH}} | ||
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'''Differential diagnosis of metabolic acidosis is as follow:'''<ref name="pmid17936961">{{cite journal |vauthors=Lim S |title=Metabolic acidosis |journal=Acta Med Indones |volume=39 |issue=3 |pages=145–50 |date=2007 |pmid=17936961 |doi= |url=}}</ref><ref name="MorrisLow2008">{{cite journal|last1=Morris|first1=C. G.|last2=Low|first2=J.|title=Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology|journal=Anaesthesia|volume=63|issue=3|year=2008|pages=294–301|issn=00032409|doi=10.1111/j.1365-2044.2007.05370.x}}</ref><ref name="pmid18336491">{{cite journal |vauthors=Morris CG, Low J |title=Metabolic acidosis in the critically ill: part 2. Causes and treatment |journal=Anaesthesia |volume=63 |issue=4 |pages=396–411 |date=April 2008 |pmid=18336491 |doi=10.1111/j.1365-2044.2007.05371.x |url=}}</ref><ref name="Casaletto2005">{{cite journal|last1=Casaletto|first1=Jennifer J.|title=Differential Diagnosis of Metabolic Acidosis|journal=Emergency Medicine Clinics of North America|volume=23|issue=3|year=2005|pages=771–787|issn=07338627|doi=10.1016/j.emc.2005.03.007}}</ref> | '''Differential diagnosis of metabolic acidosis is as follow:'''<ref name="pmid17936961">{{cite journal |vauthors=Lim S |title=Metabolic acidosis |journal=Acta Med Indones |volume=39 |issue=3 |pages=145–50 |date=2007 |pmid=17936961 |doi= |url=}}</ref><ref name="MorrisLow2008">{{cite journal|last1=Morris|first1=C. G.|last2=Low|first2=J.|title=Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology|journal=Anaesthesia|volume=63|issue=3|year=2008|pages=294–301|issn=00032409|doi=10.1111/j.1365-2044.2007.05370.x}}</ref><ref name="pmid18336491">{{cite journal |vauthors=Morris CG, Low J |title=Metabolic acidosis in the critically ill: part 2. Causes and treatment |journal=Anaesthesia |volume=63 |issue=4 |pages=396–411 |date=April 2008 |pmid=18336491 |doi=10.1111/j.1365-2044.2007.05371.x |url=}}</ref><ref name="Casaletto2005">{{cite journal|last1=Casaletto|first1=Jennifer J.|title=Differential Diagnosis of Metabolic Acidosis|journal=Emergency Medicine Clinics of North America|volume=23|issue=3|year=2005|pages=771–787|issn=07338627|doi=10.1016/j.emc.2005.03.007}}</ref> | ||
'''To review differential diagnosis of high anion gap metabolic acidosis, click here.''' | '''To review differential diagnosis of high anion gap metabolic acidosis, click [[High anion gap metabolic acidosis differential diagnosis|here]].''' | ||
'''To review differential diagnosis of high osmolar gap metabolic acidosis, click here.''' | '''To review differential diagnosis of high osmolar gap metabolic acidosis, click [[High osmolar gap metabolic acidosis differential diagnosis|here]].''' | ||
'''To review differential diagnosis of metabolic acidosis and lactic acidosis, click here.''' | '''To review differential diagnosis of metabolic acidosis and lactic acidosis, click [[Metabolic acidosis and lactic acidosis differential diagnosis|here]].''' | ||
{| | {| | ||
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| align="center" style="background:#F5F5F5;" + |Clinical manifestation | | align="center" style="background:#F5F5F5;" + |Clinical manifestation | ||
| align="left" style="background:#F5F5F5;" + | | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Toluene (toxicology)|Toluene toxicity]]<ref name="Camara-LemarroyRodríguez-Gutiérrez2015">{{cite journal|last1=Camara-Lemarroy|first1=Carlos Rodrigo|last2=Rodríguez-Gutiérrez|first2=René|last3=Monreal-Robles|first3=Roberto|last4=González-González|first4=José Gerardo|title=Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study|journal=BMC Emergency Medicine|volume=15|issue=1|year=2015|issn=1471-227X|doi=10.1186/s12873-015-0039-0}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Toluene (toxicology)|Toluene toxicity]]<ref name="Camara-LemarroyRodríguez-Gutiérrez2015">{{cite journal|last1=Camara-Lemarroy|first1=Carlos Rodrigo|last2=Rodríguez-Gutiérrez|first2=René|last3=Monreal-Robles|first3=Roberto|last4=González-González|first4=José Gerardo|title=Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study|journal=BMC Emergency Medicine|volume=15|issue=1|year=2015|issn=1471-227X|doi=10.1186/s12873-015-0039-0}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation | | align="center" style="background:#F5F5F5;" + |Clinical manifestation | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Amphotericin B]]<ref name="BatesSu2001">{{cite journal|last1=Bates|first1=D. W.|last2=Su|first2=L.|last3=Yu|first3=D. T.|last4=Chertow|first4=G. M.|last5=Seger|first5=D. L.|last6=Gomes|first6=D. R. J.|last7=Dasbach|first7=E. J.|last8=Platt|first8=R.|title=Mortality and Costs of Acute Renal Failure Associated with Amphotericin B Therapy|journal=Clinical Infectious Diseases|volume=32|issue=5|year=2001|pages=686–693|issn=1058-4838|doi=10.1086/319211}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Amphotericin B]]<ref name="BatesSu2001">{{cite journal|last1=Bates|first1=D. W.|last2=Su|first2=L.|last3=Yu|first3=D. T.|last4=Chertow|first4=G. M.|last5=Seger|first5=D. L.|last6=Gomes|first6=D. R. J.|last7=Dasbach|first7=E. J.|last8=Platt|first8=R.|title=Mortality and Costs of Acute Renal Failure Associated with Amphotericin B Therapy|journal=Clinical Infectious Diseases|volume=32|issue=5|year=2001|pages=686–693|issn=1058-4838|doi=10.1086/319211}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation | | align="center" style="background:#F5F5F5;" + |Clinical manifestation | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Carbon monoxide poisoning]]<ref name="pmid10333448">{{cite journal |vauthors=Piantadosi CA |title=Diagnosis and treatment of carbon monoxide poisoning |journal=Respir Care Clin N Am |volume=5 |issue=2 |pages=183–202 |date=June 1999 |pmid=10333448 |doi= |url=}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Carbon monoxide poisoning]]<ref name="pmid10333448">{{cite journal |vauthors=Piantadosi CA |title=Diagnosis and treatment of carbon monoxide poisoning |journal=Respir Care Clin N Am |volume=5 |issue=2 |pages=183–202 |date=June 1999 |pmid=10333448 |doi= |url=}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation | | align="center" style="background:#F5F5F5;" + |Clinical manifestation | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Cyanide poisoning]]<ref name="pmid12352039">{{cite journal |vauthors=Baud FJ, Borron SW, Mégarbane B, Trout H, Lapostolle F, Vicaut E, Debray M, Bismuth C |title=Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning |journal=Crit. Care Med. |volume=30 |issue=9 |pages=2044–50 |date=September 2002 |pmid=12352039 |doi=10.1097/01.CCM.0000026325.65944.7D |url=}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Cyanide poisoning]]<ref name="pmid12352039">{{cite journal |vauthors=Baud FJ, Borron SW, Mégarbane B, Trout H, Lapostolle F, Vicaut E, Debray M, Bismuth C |title=Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning |journal=Crit. Care Med. |volume=30 |issue=9 |pages=2044–50 |date=September 2002 |pmid=12352039 |doi=10.1097/01.CCM.0000026325.65944.7D |url=}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Blood [[cyanide]] concentration | | align="center" style="background:#F5F5F5;" + |Blood [[cyanide]] concentration | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Category | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Category | ||
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| align="center" style="background:#F5F5F5;" + |↑↑ | | align="center" style="background:#F5F5F5;" + |↑↑ | ||
| align="center" style="background:#F5F5F5;" + |Nl | | align="center" style="background:#F5F5F5;" + |Nl | ||
| align="center" style="background:#F5F5F5;" + | | | align="center" style="background:#F5F5F5;" + |↑ | ||
| align="center" style="background:#F5F5F5;" + |↓ | | align="center" style="background:#F5F5F5;" + |↓ | ||
| align="center" style="background:#F5F5F5;" + |↑ | | align="center" style="background:#F5F5F5;" + |↑ | ||
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| align="center" style="background:#F5F5F5;" + |Clinical + [[hyperglycemia]] + [[ketosis]] | | align="center" style="background:#F5F5F5;" + |Clinical + [[hyperglycemia]] + [[ketosis]] | ||
| align="left" style="background:#F5F5F5;" + | | | align="left" style="background:#F5F5F5;" + | | ||
* Labs might show elevated | * Labs might show elevated K<sup>+</sup> even in K<sup>+</sup> depletion due to extravasation of [[intracellular]] K+ in exchanged with extracellular H<sup>+</sup> | ||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |Starvation<ref name="pmid27752032">{{cite journal |vauthors=Mostert M, Bonavia A |title=Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period |journal=Am J Case Rep |volume=17 |issue= |pages=755–758 |date=October 2016 |pmid=27752032 |pmc=5070574 |doi= |url=}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |Starvation<ref name="pmid27752032">{{cite journal |vauthors=Mostert M, Bonavia A |title=Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period |journal=Am J Case Rep |volume=17 |issue= |pages=755–758 |date=October 2016 |pmid=27752032 |pmc=5070574 |doi= |url=}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + | − | | align="center" style="background:#F5F5F5;" + | − | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation | | align="center" style="background:#F5F5F5;" + |Clinical manifestation | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* [[Refeeding syndrome]] may occur during or after treatment | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |Alcoholic ketoacidosis ([[Ethanol]])<ref name="pmid28613672">{{cite journal |vauthors=Howard RD, Bokhari SRA |title= |journal= |volume= |issue= |pages= |date= |pmid=28613672 |doi= |url=}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |Alcoholic ketoacidosis ([[Ethanol]])<ref name="pmid28613672">{{cite journal |vauthors=Howard RD, Bokhari SRA |title= |journal= |volume= |issue= |pages= |date= |pmid=28613672 |doi= |url=}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | | align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Ischemia]]<ref name="KimmounNovy2015">{{cite journal|last1=Kimmoun|first1=Antoine|last2=Novy|first2=Emmanuel|last3=Auchet|first3=Thomas|last4=Ducrocq|first4=Nicolas|last5=Levy|first5=Bruno|title=Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside|journal=Critical Care|volume=19|issue=1|year=2015|issn=1364-8535|doi=10.1186/s13054-015-0896-7}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Ischemia]]<ref name="KimmounNovy2015">{{cite journal|last1=Kimmoun|first1=Antoine|last2=Novy|first2=Emmanuel|last3=Auchet|first3=Thomas|last4=Ducrocq|first4=Nicolas|last5=Levy|first5=Bruno|title=Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside|journal=Critical Care|volume=19|issue=1|year=2015|issn=1364-8535|doi=10.1186/s13054-015-0896-7}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | | align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Lactic acidosis]]<ref name="KrautIngelfinger2014">{{cite journal|last1=Kraut|first1=Jeffrey A.|last2=Ingelfinger|first2=Julie R.|last3=Madias|first3=Nicolaos E.|title=Lactic Acidosis|journal=New England Journal of Medicine|volume=371|issue=24|year=2014|pages=2309–2319|issn=0028-4793|doi=10.1056/NEJMra1309483}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Lactic acidosis]]<ref name="KrautIngelfinger2014">{{cite journal|last1=Kraut|first1=Jeffrey A.|last2=Ingelfinger|first2=Julie R.|last3=Madias|first3=Nicolaos E.|title=Lactic Acidosis|journal=New England Journal of Medicine|volume=371|issue=24|year=2014|pages=2309–2319|issn=0028-4793|doi=10.1056/NEJMra1309483}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + | − | | align="center" style="background:#F5F5F5;" + | − | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | | align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
| rowspan="5" align="center" style="background:#4479BA; color: #FFFFFF;" + |Renal | | rowspan="5" align="center" style="background:#4479BA; color: #FFFFFF;" + |Renal | ||
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| align="center" style="background:#F5F5F5;" + | − | | align="center" style="background:#F5F5F5;" + | − | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | | align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* May lead to [[pericarditis]] | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Renal failure]]<ref name="KrautMadias2016">{{cite journal|last1=Kraut|first1=Jeffrey A.|last2=Madias|first2=Nicolaos E.|title=Metabolic Acidosis of CKD: An Update|journal=American Journal of Kidney Diseases|volume=67|issue=2|year=2016|pages=307–317|issn=02726386|doi=10.1053/j.ajkd.2015.08.028}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Renal failure]]<ref name="KrautMadias2016">{{cite journal|last1=Kraut|first1=Jeffrey A.|last2=Madias|first2=Nicolaos E.|title=Metabolic Acidosis of CKD: An Update|journal=American Journal of Kidney Diseases|volume=67|issue=2|year=2016|pages=307–317|issn=02726386|doi=10.1053/j.ajkd.2015.08.028}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + | − | | align="center" style="background:#F5F5F5;" + | − | ||
| align="center" style="background:#F5F5F5;" + |[[Renal function tests|Renal function test]] | | align="center" style="background:#F5F5F5;" + |[[Renal function tests|Renal function test]] | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! rowspan="3" align="center" style="background:#DCDCDC;" + |[[Renal tubular acidosis]]<ref name="Gil-PeñaMejía2014">{{cite journal|last1=Gil-Peña|first1=Helena|last2=Mejía|first2=Natalia|last3=Santos|first3=Fernando|title=Renal Tubular Acidosis|journal=The Journal of Pediatrics|volume=164|issue=4|year=2014|pages=691–698.e1|issn=00223476|doi=10.1016/j.jpeds.2013.10.085}}</ref> | ! rowspan="3" align="center" style="background:#DCDCDC;" + |[[Renal tubular acidosis]]<ref name="Gil-PeñaMejía2014">{{cite journal|last1=Gil-Peña|first1=Helena|last2=Mejía|first2=Natalia|last3=Santos|first3=Fernando|title=Renal Tubular Acidosis|journal=The Journal of Pediatrics|volume=164|issue=4|year=2014|pages=691–698.e1|issn=00223476|doi=10.1016/j.jpeds.2013.10.085}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | | align="center" style="background:#F5F5F5;" + |Clinical manifestation and lab finding | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! align="center" style="background:#DCDCDC;" + |Type IV | ! align="center" style="background:#DCDCDC;" + |Type IV | ||
| Line 916: | Line 928: | ||
| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |Clinical manifestation + [[ECG]] | | align="center" style="background:#F5F5F5;" + |Clinical manifestation + [[ECG]] | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" + |GI | ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" + |GI | ||
| Line 930: | Line 943: | ||
| align="center" style="background:#F5F5F5;" + |↓ | | align="center" style="background:#F5F5F5;" + |↓ | ||
| align="center" style="background:#F5F5F5;" + | + | | align="center" style="background:#F5F5F5;" + | + | ||
| align="center" style="background:#F5F5F5;" + | | | align="center" style="background:#F5F5F5;" + |May be lethargic | ||
| align="center" style="background:#F5F5F5;" + |↓ | | align="center" style="background:#F5F5F5;" + |↓ | ||
| align="center" style="background:#F5F5F5;" + |↓ | | align="center" style="background:#F5F5F5;" + |↓ | ||
| Line 950: | Line 963: | ||
| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |[[Stool examination|Stool exam]] | | align="center" style="background:#F5F5F5;" + |[[Stool examination|Stool exam]] | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Hyperalimentation]]<ref name="ErlingssonHerard2009">{{cite journal|last1=Erlingsson|first1=Styrbjörn|last2=Herard|first2=Sebastian|last3=Dahlqvist Leinhard|first3=Olof|last4=Lindström|first4=Torbjörb|last5=Länne|first5=Toste|last6=Borga|first6=Magnus|last7=Nystrom|first7=Fredrik H.|title=Men develop more intraabdominal obesity and signs of the metabolic syndrome after hyperalimentation than women|journal=Metabolism|volume=58|issue=7|year=2009|pages=995–1001|issn=00260495|doi=10.1016/j.metabol.2009.02.028}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Hyperalimentation]]<ref name="ErlingssonHerard2009">{{cite journal|last1=Erlingsson|first1=Styrbjörn|last2=Herard|first2=Sebastian|last3=Dahlqvist Leinhard|first3=Olof|last4=Lindström|first4=Torbjörb|last5=Länne|first5=Toste|last6=Borga|first6=Magnus|last7=Nystrom|first7=Fredrik H.|title=Men develop more intraabdominal obesity and signs of the metabolic syndrome after hyperalimentation than women|journal=Metabolism|volume=58|issue=7|year=2009|pages=995–1001|issn=00260495|doi=10.1016/j.metabol.2009.02.028}}</ref> | ||
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| align="center" style="background:#F5F5F5;" + |Clinical manifestation | | align="center" style="background:#F5F5F5;" + |Clinical manifestation | ||
| align="left" style="background:#F5F5F5;" + | | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Liver failure]]<ref name="LangeBojunga2009">{{cite journal|last1=Lange|first1=Christian M.|last2=Bojunga|first2=Jörg|last3=Hofmann|first3=Wolf Peter|last4=Wunder|first4=Katrin|last5=Mihm|first5=Ulrike|last6=Zeuzem|first6=Stefan|last7=Sarrazin|first7=Christoph|title=Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function|journal=Hepatology|volume=50|issue=6|year=2009|pages=2001–2006|issn=02709139|doi=10.1002/hep.23346}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Liver failure]]<ref name="LangeBojunga2009">{{cite journal|last1=Lange|first1=Christian M.|last2=Bojunga|first2=Jörg|last3=Hofmann|first3=Wolf Peter|last4=Wunder|first4=Katrin|last5=Mihm|first5=Ulrike|last6=Zeuzem|first6=Stefan|last7=Sarrazin|first7=Christoph|title=Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function|journal=Hepatology|volume=50|issue=6|year=2009|pages=2001–2006|issn=02709139|doi=10.1002/hep.23346}}</ref> | ||
| Line 1,017: | Line 1,032: | ||
| align="center" style="background:#F5F5F5;" + |[[Liver biopsy]] | | align="center" style="background:#F5F5F5;" + |[[Liver biopsy]] | ||
| align="left" style="background:#F5F5F5;" + | | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Endocrine | ! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Endocrine | ||
| Line 1,050: | Line 1,066: | ||
| align="center" style="background:#F5F5F5;" + |− | | align="center" style="background:#F5F5F5;" + |− | ||
| align="center" style="background:#F5F5F5;" + |[[Parathyroid hormone|PTH]] level | | align="center" style="background:#F5F5F5;" + |[[Parathyroid hormone|PTH]] level | ||
| align=" | | align="left" style="background:#F5F5F5;" + | | ||
* Not applicable | |||
|- | |- | ||
! colspan="2" align="center" style="background:#DCDCDC;" + |[[Addison's disease]]<ref name="TenNew2001">{{cite journal|last1=Ten|first1=Svetlana|last2=New|first2=Maria|last3=Maclaren|first3=Noel|title=Addison’s Disease 2001|journal=The Journal of Clinical Endocrinology & Metabolism|volume=86|issue=7|year=2001|pages=2909–2922|issn=0021-972X|doi=10.1210/jcem.86.7.7636}}</ref> | ! colspan="2" align="center" style="background:#DCDCDC;" + |[[Addison's disease]]<ref name="TenNew2001">{{cite journal|last1=Ten|first1=Svetlana|last2=New|first2=Maria|last3=Maclaren|first3=Noel|title=Addison’s Disease 2001|journal=The Journal of Clinical Endocrinology & Metabolism|volume=86|issue=7|year=2001|pages=2909–2922|issn=0021-972X|doi=10.1210/jcem.86.7.7636}}</ref> | ||
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==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Medicine]] | |||
[[Category:Nephrology]] | |||
[[Category:Up-To-Date]] | |||
Latest revision as of 22:43, 29 July 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]
Overview
Metabolic acidosis is occured in different situations such as poisoning, ketoacidosis, renal, gastrointestinal, cardiac, endocrine, and systemic diseases.
Metabolic Acidosis Differential Diagnosis
Differential diagnosis of metabolic acidosis is as follow:[1][2][3][4]
To review differential diagnosis of high anion gap metabolic acidosis, click here.
To review differential diagnosis of high osmolar gap metabolic acidosis, click here.
To review differential diagnosis of metabolic acidosis and lactic acidosis, click here.
| Category | Disease | Mechanism | Clinical | Paraclinical | Gold standard diagnosis | Other findings | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Symptoms | Signs | Lab data | |||||||||||||||||||||||||||||||
| ABG | CBC | Chemistry | Renal | U/A | |||||||||||||||||||||||||||||
| ↑ acid production |
Loss of bicarbonate |
↓ renal acid excretion |
Fever | N/V | Diarrhea | Dyspnea | Toxic/ill | BP | Dehydration | Level of consciousness | HCO3− | paCO2 | O2 | WBC | Hb | BS | Cl− | K+ | Na+ | Ketones | Lactic acid | Serum AG[5] | Osmolar gap[6] | Bun | Cr | Urine pH | Urine AG | Urine ketone | |||||
| Toxin/Medication[7] | Alcohol poisoning[8][9] | + | − | − | − | + | − | − | + | ↓ ↑ | + | ↓ | ↓ | ↓ | ↓ | Nl | Nl | ↑ | ↑ | ↑ | Nl | + | ↑ | ↑ | ↑ | Nl or ↑ | Nl or ↑ | ↓ | + | + | Clinical manifestation |
| |
| + | − | − | − | + | − | − | + | ↓ | + | ↓ | ↓ | ↓ | ↓ | Nl | Nl | Nl | ↑ | ↑ | Nl | + | ↑ | Nl | ↑ | Nl | Nl or ↑ | ↓ | + | + | Clinical manifestation |
| |||
| Toluene toxicity[11] | + | − | + | − | + | − | − | + | ↓ | − | ↓ | ↓↓ | ↓ | Nl | Nl | Nl | Nl | Nl | ↓ | Nl | − | ↑ | Nl or ↑ | Nl | ↑ | ↑ | ↓ | − | + | Clinical manifestation |
| ||
| Salicylates overdose[12] | + | − | − | − | + | − | + | + | ↓ | + | ↓ | ↓ | ↓↓ | ↓ | Nl | Nl | Nl to ↓ | Nl | ↓ | Nl | − | ↑ | ↑ | ↑ | ↑ | ↑ | ↓ | − | − | Clinical and elevated serum salicylate level |
| ||
| Metformin[13] | + | − | − | − | + | − | − | + | ↓ | ± | Agitated | ↓ | ↓ | Nl | Nl to ↑ | ↓ | ↓ | Nl | Nl | Nl | Nl | ↑ | ↑ | ↑ | Nl or ↑ | Nl | ↓ | − | − | Clinical manifestation |
| ||
| Isoniazid[14] | + | − | − | − | + | − | − | + | ↑ | + | Agitated | ↓ | ↓ | Nl | Nl | ↓ | Nl | Nl | Nl | Nl | Nl | ↑ | ↑ | Nl | Nl or ↑ | Nl | ↓ | − | − | Clinical manifestation | |||
| Acetazolamide[15] | − | + | − | − | − | − | − | − | ↓ | + | Nl | ↓ | ↓ | Nl to ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl or ↑ | Nl | ↓ | − | − | Clinical manifestation |
| ||
| Amphotericin B[16] | − | − | + | − | + | + | − | + | ↓ | + | ↓ | ↓ | ↓ | Nl to ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | ↑ | ↑ | ↓ | − | − | Clinical manifestation |
| ||
| Carbon monoxide poisoning[17] | + | − | + | − | ± | − | − | + | Nl | − | ↓↓ | ↓ | ↓ | Nl to ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | ↑ | ↑ | Nl | Nl | Nl | ↓ | − | − | Clinical manifestation |
| ||
| Cyanide poisoning[18] | + | − | − | − | + | − | − | + | ↓ | ± | ↓↓ | ↓ | ↓ | ↓ | Nl to ↑ | ↓ | Nl | Nl | Nl | Nl | Nl | ↑ | ↑ | Nl | Nl or ↑ | Nl | ↓ | − | − | Blood cyanide concentration |
| ||
| Category | Disease | ↑ acid production |
Loss of bicarbonate |
↓ renal acid excretion |
Fever | N/V | Diarrhea | Dyspnea | Toxic/ill | BP | Dehydration | Level of consciousness | HCO3− | paCO2 | O2 | WBC | Hb | BS | Cl− | K+ | Na+ | Ketones | Lactic acid | Serum AG | Osmolar gap | Bun | Cr | Urine pH | Urine AG | Urine ketone | Gold standard diagnosis | Other findings | |
| Ketoacidosis | Diabetic ketoacidosis[19] | + | − | − | + | + | + | + | + | ↓ | + | ↓ | ↓ | ↓ | Nl to ↓ | ↑ | Nl to ↑ | ↑↑ | Nl | ↑ | ↓ | ↑ | ↑ | ↑ | ↑ | Nl to ↑ | Nl | ↓ | + | + | Clinical + hyperglycemia + ketosis |
| |
| Starvation[20] | + | − | − | − | + | − | − | + | ↓ | + | ↓ | ↓ | ↓ | Nl | Nl | Nl | Nl to ↓ | Nl | ↓ | ↓ | ↑ | Nl | ↑ | Nl | Nl | Nl | Nl | + | − | Clinical manifestation |
| ||
| Alcoholic ketoacidosis (Ethanol)[21] | + | − | − | − | + | ± | − | + | ↓ ↑ | + | Agitated | ↓ | ↓ | ↓ | Nl to ↑ | Nl to ↑ | ↓ Nl ↑ | Nl | ↓ | ↓ | ↑↑ | ↑ | ↑ | ↑↑ | ↑ | Nl | ↓ | + | + | Clinical manifestation + ketosis |
| ||
| Systemic | Sepsis[22] | + | − | − | + | + | − | + | + | ↓ ↑ | + | ↓ | ↓ | ↓ | Nl to ↓ | ↑ | Nl | Nl | Nl | ↑ | ↓ | Nl | Nl to ↑ | Nl | Nl | ↑ | ↑ | Nl | − | − | Clinical manifestation and lab finding |
| |
| Ischemia[23] | + | − | − | − | + | − | + | + | ↓ | + | − | ↓ | ↓ ↑ | Nl to ↓ | Nl to ↑ | Nl | Nl | Nl | ↑ | ↓ | Nl | Nl to ↑ | Nl | Nl | Nl to ↑ | Nl to ↑ | Nl | − | − | Clinical manifestation and lab finding |
| ||
| Lactic acidosis[24] | + | − | − | ± | + | − | − | + | ↓ ↑ | ± | Agitated | ↓ | ↓ | ↓ | Nl to ↑ | ↓ | Nl | Nl | Nl | Nl | Nl | ↑ | ↑ | ↑ | Nl or ↑ | Nl | ↓ | − | − | Clinical manifestation and lab finding |
| ||
| Renal | Uremia[25] | − | − | + | + | + | − | − | + | ↓ ↑ | ± | ↓ | ↓ | ↓ | Nl to ↓ | ↑ | ↓ | Nl | Nl | ↑ | ↑ | Nl | Nl | ↑ | ↑ | ↑ | ↑ | ↓ | + | − | Clinical manifestation and lab finding |
| |
| Renal failure[26] | − | − | + | − | + | − | − | + | ↓ | + | ↓ | ↓ | ↓ | Nl to ↓ | ↑ | ↓ | Nl | ↑ | ↑ | ↓ | Nl | Nl | ↑ | ↑ | ↑ | ↑ | ↓ | − | − | Renal function test |
| ||
| Renal tubular acidosis[27] | Type I[28] | − | − | + | ± | ± | − | − | − | ↓ ↑ | − | − | ↓ | ↓ | Nl | Nl | Nl | Nl | ↑ | ↓ | ↓ | Nl | Nl | Nl | Nl | ↑ | ↑ | ↑ | + | − | Clinical manifestation and lab finding |
| |
| Type II | − | + | − | ± | ± | − | − | − | ↓ ↑ | − | − | ↓ | ↓ | Nl | Nl | Nl | Nl | ↑ | ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | − | − | Clinical manifestation and lab finding |
| ||
| Type IV | − | − | + | ± | ± | ± | − | − | ↓ | − | − | ↓ | ↓ | Nl | Nl | Nl | Nl | ↑ | ↑ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | + | − | Clinical manifestation and lab finding | |||
| Category | Disease | ↑ acid production |
Loss of bicarbonate |
↓ renal acid excretion |
Fever | N/V | Diarrhea | Dyspnea | Toxic/ill | BP | Dehydration | Level of consciousness | HCO3− | paCO2 | O2 | WBC | Hb | BS | Cl− | K+ | Na+ | Ketones | Lactic acid | Serum AG | Osmolar gap | Bun | Cr | Urine pH | Urine AG | Urine ketone | Gold standard diagnosis | Other findings | |
| Heart | Heart failure[29] | + | + | − | − | ± | − | + | + | ↓ ↑ | + | − | ↓ | ↓ ↑ | ↓ | Nl | Nl | Nl | Nl | ↓ | ↓ | Nl | Nl | Nl | Nl | Nl to ↑ | Nl to ↑ | Nl | − | − | Clinical manifestation+ echocardiogram |
| |
| Myocardial infarction[30] | + | − | − | − | + | − | + | + | ↓ ↑ | − | ↓ | ↓ | ↓ ↑ | Nl to ↓ | Nl to ↑ | Nl | Nl | Nl | ↑ | ↓ | Nl | ↑ | Nl | Nl | Nl to ↑ | Nl to ↑ | Nl | − | − | Clinical manifestation + ECG |
| ||
| GI | Diarrhea[31] | − | + | − | ± | + | + | − | + | ↓ | + | May be lethargic | ↓ | ↓ | Nl | Nl | ↓ | ↓ | ↑ | ↑ | Nl | Nl | Nl | Nl | Nl | ↑ | Nl | Nl | − | − | Stool exam |
| |
| Hyperalimentation[32] | + | + | − | − | − | + | − | − | Nl | − | − | ↓ | ↓ | Nl | Nl | ↓ | Nl | ↑ | ↑ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | − | − | Clinical manifestation |
| ||
| Liver failure[33] | − | + | − | − | + | + | − | + | ↓ | + | Confused | ↓ | ↓ | Nl | Nl | ↓ | ↓ ↑ | ↑ | ↓ | ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | − | − | Liver biopsy |
| ||
| Endocrine | Hyperparathyroidism[34] | − | + | + | − | + | − | − | − | Nl | + | Confused | ↓ | ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl | Nl to ↑ | Nl | Nl | − | − | PTH level |
| |
| Addison's disease[35] | − | + | − | − | + | + | − | − | ↓ | + | Irritable | ↓ | ↓ | Nl | Nl | Nl | ↓ | Nl | ↑ | ↓ | Nl | Nl | Nl | Nl | Nl | Nl | Nl | − | − | Hormone level | |||
| Category | Disease | ↑ acid production |
Loss of bicarbonate |
↓ renal acid excretion |
Fever | N/V | Diarrhea | Dyspnea | Toxic/ill | BP | Dehydration | Level of consciousness | HCO3− | paCO2 | O2 | WBC | Hb | BS | Cl− | K+ | Na+ | Ketones | Lactic acid | Serum AG | Osmolar gap | Bun | Cr | Urine pH | Urine AG | Urine ketone | Gold standard diagnosis | Other findings | |
References
- ↑ Lim S (2007). "Metabolic acidosis". Acta Med Indones. 39 (3): 145–50. PMID 17936961.
- ↑ Morris, C. G.; Low, J. (2008). "Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology". Anaesthesia. 63 (3): 294–301. doi:10.1111/j.1365-2044.2007.05370.x. ISSN 0003-2409.
- ↑ Morris CG, Low J (April 2008). "Metabolic acidosis in the critically ill: part 2. Causes and treatment". Anaesthesia. 63 (4): 396–411. doi:10.1111/j.1365-2044.2007.05371.x. PMID 18336491.
- ↑ Casaletto, Jennifer J. (2005). "Differential Diagnosis of Metabolic Acidosis". Emergency Medicine Clinics of North America. 23 (3): 771–787. doi:10.1016/j.emc.2005.03.007. ISSN 0733-8627.
- ↑ Brubaker RH, Meseeha M. High Anion Gap Metabolic Acidosis. [Updated 2017 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448090/
- ↑ Kraut JA, Xing SX (September 2011). "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". Am. J. Kidney Dis. 58 (3): 480–4. doi:10.1053/j.ajkd.2011.05.018. PMID 21794966.
- ↑ Pham, Amy Quynh Trang; Xu, Li Hao Richie; Moe, Orson W. (2015). "Drug-Induced Metabolic Acidosis". F1000Research. doi:10.12688/f1000research.7006.1. ISSN 2046-1402.
- ↑ Zehtabchi S, Sinert R, Baron BJ, Paladino L, Yadav K (2005). "Does ethanol explain the acidosis commonly seen in ethanol-intoxicated patients?". Clin Toxicol (Phila). 43 (3): 161–6. PMID 15902789.
- ↑ Roberts, Darren M.; Yates, Christopher; Megarbane, Bruno; Winchester, James F.; Maclaren, Robert; Gosselin, Sophie; Nolin, Thomas D.; Lavergne, Valéry; Hoffman, Robert S.; Ghannoum, Marc (2015). "Recommendations for the Role of Extracorporeal Treatments in the Management of Acute Methanol Poisoning". Critical Care Medicine. 43 (2): 461–472. doi:10.1097/CCM.0000000000000708. ISSN 0090-3493.
- ↑ Ashurst JV, Nappe TM. Toxicity, Isopropanol. [Updated 2018 Mar 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493181/
- ↑ Camara-Lemarroy, Carlos Rodrigo; Rodríguez-Gutiérrez, René; Monreal-Robles, Roberto; González-González, José Gerardo (2015). "Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study". BMC Emergency Medicine. 15 (1). doi:10.1186/s12873-015-0039-0. ISSN 1471-227X.
- ↑ Wright, Dallas; Sop, Jessica (2015). "Normal anion gap salicylate poisoning". The American Journal of Emergency Medicine. 33 (11): 1714.e3–1714.e4. doi:10.1016/j.ajem.2015.03.042. ISSN 0735-6757.
- ↑ Galiero, Francesca; Consani, Giovanni; Biancofiore, Gianni; Ruschi, Stefano; Forfori, Francesco (2018). "Metformin intoxication: Vasopressin's key role in the management of severe lactic acidosis". The American Journal of Emergency Medicine. 36 (2): 341.e5–341.e6. doi:10.1016/j.ajem.2017.10.057. ISSN 0735-6757.
- ↑ Watkins RC, Hambrick EL, Benjamin G, Chavda SN (January 1990). "Isoniazid toxicity presenting as seizures and metabolic acidosis". J Natl Med Assoc. 82 (1): 57, 62, 64. PMC 2625939. PMID 2304098.
- ↑ Teppema, Luc J.; Balanos, George M.; Steinback, Craig D.; Brown, Allison D.; Foster, Glen E.; Duff, Henry J.; Leigh, Richard; Poulin, Marc J. (2007). "Effects of Acetazolamide on Ventilatory, Cerebrovascular, and Pulmonary Vascular Responses to Hypoxia". American Journal of Respiratory and Critical Care Medicine. 175 (3): 277–281. doi:10.1164/rccm.200608-1199OC. ISSN 1073-449X.
- ↑ Bates, D. W.; Su, L.; Yu, D. T.; Chertow, G. M.; Seger, D. L.; Gomes, D. R. J.; Dasbach, E. J.; Platt, R. (2001). "Mortality and Costs of Acute Renal Failure Associated with Amphotericin B Therapy". Clinical Infectious Diseases. 32 (5): 686–693. doi:10.1086/319211. ISSN 1058-4838.
- ↑ Piantadosi CA (June 1999). "Diagnosis and treatment of carbon monoxide poisoning". Respir Care Clin N Am. 5 (2): 183–202. PMID 10333448.
- ↑ Baud FJ, Borron SW, Mégarbane B, Trout H, Lapostolle F, Vicaut E, Debray M, Bismuth C (September 2002). "Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning". Crit. Care Med. 30 (9): 2044–50. doi:10.1097/01.CCM.0000026325.65944.7D. PMID 12352039.
- ↑ Wolfsdorf, Joseph I; Allgrove, Jeremy; Craig, Maria E; Edge, Julie; Glaser, Nicole; Jain, Vandana; Lee, Warren WR; Mungai, Lucy NW; Rosenbloom, Arlan L; Sperling, Mark A; Hanas, Ragnar (2014). "Diabetic ketoacidosis and hyperglycemic hyperosmolar state". Pediatric Diabetes. 15 (S20): 154–179. doi:10.1111/pedi.12165. ISSN 1399-543X.
- ↑ Mostert M, Bonavia A (October 2016). "Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period". Am J Case Rep. 17: 755–758. PMC 5070574. PMID 27752032.
- ↑ Howard RD, Bokhari S. PMID 28613672. Vancouver style error: initials (help); Missing or empty
|title=(help) - ↑ Ganesh K, Sharma RN, Varghese J, Pillai MG (2016). "A profile of metabolic acidosis in patients with sepsis in an Intensive Care Unit setting". Int J Crit Illn Inj Sci. 6 (4): 178–181. doi:10.4103/2229-5151.195417. PMC 5225760. PMID 28149822.
- ↑ Kimmoun, Antoine; Novy, Emmanuel; Auchet, Thomas; Ducrocq, Nicolas; Levy, Bruno (2015). "Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside". Critical Care. 19 (1). doi:10.1186/s13054-015-0896-7. ISSN 1364-8535.
- ↑ Kraut, Jeffrey A.; Ingelfinger, Julie R.; Madias, Nicolaos E. (2014). "Lactic Acidosis". New England Journal of Medicine. 371 (24): 2309–2319. doi:10.1056/NEJMra1309483. ISSN 0028-4793.
- ↑ Brown, Denver; Melamed, Michal L. (2018). "New Frontiers in Treating Uremic Metabolic Acidosis". Clinical Journal of the American Society of Nephrology. 13 (1): 4–5. doi:10.2215/CJN.11771017. ISSN 1555-9041.
- ↑ Kraut, Jeffrey A.; Madias, Nicolaos E. (2016). "Metabolic Acidosis of CKD: An Update". American Journal of Kidney Diseases. 67 (2): 307–317. doi:10.1053/j.ajkd.2015.08.028. ISSN 0272-6386.
- ↑ Gil-Peña, Helena; Mejía, Natalia; Santos, Fernando (2014). "Renal Tubular Acidosis". The Journal of Pediatrics. 164 (4): 691–698.e1. doi:10.1016/j.jpeds.2013.10.085. ISSN 0022-3476.
- ↑ Hemstreet, Brian A (2004). "Antimicrobial-Associated Renal Tubular Acidosis". Annals of Pharmacotherapy. 38 (6): 1031–1038. doi:10.1345/aph.1D573. ISSN 1060-0280.
- ↑ Park, Jin Joo; Choi, Dong-Ju; Yoon, Chang-Hwan; Oh, Il-Young; Lee, Ju Hyun; Ahn, Soyeon; Yoo, Byung-Su; Kang, Seok-Min; Kim, Jae-Joong; Baek, Sang-Hong; Cho, Myeong-Chan; Jeon, Eun-Seok; Chae, Shung Chull; Ryu, Kyu-Hyung; Oh, Byung-Hee (2015). "The prognostic value of arterial blood gas analysis in high-risk acute heart failure patients: an analysis of the Korean Heart Failure (KorHF) registry". European Journal of Heart Failure. 17 (6): 601–611. doi:10.1002/ejhf.276. ISSN 1388-9842.
- ↑ Mann, Sarah; Bajulaiye, Akinyemi; Sturgeon, Kathleen; Sabri, Abdelkarim; Muthukumaran, Geetha; Libonati, Joseph R. (2014). "Effects of acute angiotensin II on ischemia reperfusion injury following myocardial infarction". Journal of the Renin-Angiotensin-Aldosterone System. 16 (1): 13–22. doi:10.1177/1470320314554963. ISSN 1470-3203.
- ↑ Guerrant, R. L.; Van Gilder, T.; Steiner, T. S.; Thielman, N. M.; Slutsker, L.; Tauxe, R. V.; Hennessy, T.; Griffin, P. M.; DuPont, H.; Bradley Sack, R.; Tarr, P.; Neill, M.; Nachamkin, I.; Reller, L. B.; Osterholm, M. T.; Bennish, M. L.; Pickering, L. K. (2001). "Practice Guidelines for the Management of Infectious Diarrhea". Clinical Infectious Diseases. 32 (3): 331–351. doi:10.1086/318514. ISSN 1058-4838.
- ↑ Erlingsson, Styrbjörn; Herard, Sebastian; Dahlqvist Leinhard, Olof; Lindström, Torbjörb; Länne, Toste; Borga, Magnus; Nystrom, Fredrik H. (2009). "Men develop more intraabdominal obesity and signs of the metabolic syndrome after hyperalimentation than women". Metabolism. 58 (7): 995–1001. doi:10.1016/j.metabol.2009.02.028. ISSN 0026-0495.
- ↑ Lange, Christian M.; Bojunga, Jörg; Hofmann, Wolf Peter; Wunder, Katrin; Mihm, Ulrike; Zeuzem, Stefan; Sarrazin, Christoph (2009). "Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function". Hepatology. 50 (6): 2001–2006. doi:10.1002/hep.23346. ISSN 0270-9139.
- ↑ Bilezikian, John P.; Potts, John T.; Fuleihan, Ghada El-Hajj; Kleerekoper, Michael; Neer, Robert; Peacock, Munro; Rastad, Jonas; Silverberg, Shonni J.; Udelsman, Robert; Wells, Samuel A. (2002). "Summary Statement from a Workshop on Asymptomatic Primary Hyperparathyroidism: A Perspective for the 21st Century". The Journal of Clinical Endocrinology & Metabolism. 87 (12): 5353–5361. doi:10.1210/jc.2002-021370. ISSN 0021-972X.
- ↑ Ten, Svetlana; New, Maria; Maclaren, Noel (2001). "Addison's Disease 2001". The Journal of Clinical Endocrinology & Metabolism. 86 (7): 2909–2922. doi:10.1210/jcem.86.7.7636. ISSN 0021-972X.