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Nephrology Acid-Base Disorders Intermediate
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High Anion Gap Metabolic Acidosis

M
U
D
P
I
L
E
S
The gold-standard clinical mnemonic for etiologies of elevated serum anion gap metabolic acidosis (AG > 12 mEq/L).

The serum anion gap is calculated as [Na+] - ([Cl-] + [HCO3-]). An elevated anion gap indicates unmeasured endogenous or exogenous organic anions consuming bicarbonate buffers in the blood.

Systematic Breakdown

M

Methanol

Metabolized by alcohol dehydrogenase to toxic formic acid; causes retinal damage, 'snowfield' blindness, and putaminal necrosis.

U

Uremia (Advanced Renal Failure)

Decreased glomerular excretion of organic acids, sulfate, and phosphate.

D

Diabetic Ketoacidosis (DKA)

Insulin deficiency and glucagon excess drive beta-oxidation and production of beta-hydroxybutyrate and acetoacetate.

P

Propylene Glycol / Paraldehyde

Solvent in IV lorazepam/phenytoin; metabolized to lactic acid. Or chronic acetaminophen-induced pyroglutamic acidosis.

I

Iron Tablets / Isoniazid

Direct mitochondrial poison causing shock, hypoperfusion, and uncoupling of oxidative phosphorylation.

L

Lactic Acidosis

Type A (tissue hypoperfusion, sepsis, cardiogenic shock) or Type B (metformin toxicity, cyanide, liver failure).

E

Ethylene Glycol

Antifreeze poisoning metabolized to glycolic and oxalic acid; leads to acute tubular necrosis and calcium oxalate monohydrate envelope crystals in urine.

S

Salicylates (Aspirin)

Early respiratory alkalosis (direct medullary stimulation) followed by mixed high anion gap metabolic acidosis (uncouples oxidative phosphorylation).

High-Yield Clinical Pearls & Exam Tips
  • Osmolar Gap: Calculated Osm = 2[Na+] + [Glucose]/18 + [BUN]/2.8. A gap > 10 mOsm/kg points toward toxic alcohols (Methanol or Ethylene Glycol).
  • Antidote for toxic alcohols: Fomepizole (inhibits alcohol dehydrogenase) or hemodialysis if severe.
Related Pharmaceuticals
Fomepizole Sodium Bicarbonate Regular Insulin
Related Clinical Conditions
Diabetic Ketoacidosis Acute Kidney Injury Toxic Alcohol Ingestion
Authoritative Sources: Rose & Post Clinical Physiology of Acid-Base and Electrolyte Disorders · First Aid USMLE Step 1

More Nephrology Mnemonics

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HARD-UP

Normal Anion Gap Metabolic Acidosis

H A R D - U P

Causes of hyperchloremic (normal anion gap) metabolic acidosis (AG 8-12 mEq/L) characterized by reciprocal chloride retention.

Harrison's Principles of Internal Medicine 21e 183
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C BIG K DROP

Hyperkalemia Management Protocol: C BIG K DROP

C BIG K DROP

Step-by-step emergency medical stabilization and total body elimination of severe hyperkalemia (K+ > 6.5 mEq/L or with ECG changes).

AHA Guidelines on Electrolyte Emergencies 2,225
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BUN:Cr & FENa CHEAT SHEET

Prerenal vs Intrinsic AKI Differentiation

BUN:Cr & FENa CHEAT SHEET

Diagnostic markers differentiating prerenal hypoperfusion from intrinsic acute tubular necrosis (ATN).

KDIGO Clinical Practice Guideline for Acute Kidney Injury 2,023

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