The serum anion gap, calculated from the
electrolytes measured in the chemical laboratory, is defined as the sum of serum
chloride and
bicarbonate concentrations subtracted from the serum
sodium concentration. This entity is used in the detection and analysis of
acid-base disorders, assessment of quality control in the chemical laboratory, and detection of such disorders as
multiple myeloma,
bromide intoxication, and
lithium intoxication. The normal value can vary widely, reflecting both differences in the methods that are used to measure its constituents and substantial interindividual variability. Low values most commonly indicate laboratory error or
hypoalbuminemia but can denote the presence of a
paraproteinemia or intoxication with
lithium, bromide, or
iodide. Elevated values most commonly indicate
metabolic acidosis but can reflect laboratory error, metabolic
alkalosis,
hyperphosphatemia, or
paraproteinemia.
Metabolic acidosis can be divided into high
anion and normal anion gap varieties, which can be present alone or concurrently. A presumed 1:1 stoichiometry between change in the serum anion gap (DeltaAG) and change in the serum
bicarbonate concentration (DeltaHCO(3)(-)) has been used to uncover the concurrence of mixed metabolic
acid-base disorders in patients with high anion gap
acidosis. However, recent studies indicate variability in the DeltaAG/DeltaHCO(3)(-) in this disorder. This observation undercuts the ability to use this ratio alone to detect complex
acid-base disorders, thus emphasizing the need to consider additional information to obtain the appropriate diagnosis. Despite these caveats, calculation of the serum anion gap remains an inexpensive and effective tool that
aids detection of various
acid-base disorders,
hematologic malignancies, and intoxications.