Pseudo-anion gap metabolic acidosis from severe hypertriglyceridemia corrected by plasma exchange

Carag, Charissa; Baxi, Pravir V.; Behara, Venkata; Gashti, Casey N.; Rodby, Roger A.

doi:10.5414/cn109627

Cited by 11 publications

(7 citation statements)

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“…Interestingly, the Abbott i-STAT uses an enzymatic system dependent on photometric analysis, which has been tested in vitro with intralipid to lipid levels as high as 111 mmol/L, with no significant interference found. 27 29 However, there is no available data on higher concentrations (our patient had a serum TG of 267.66 mmol/L), and recommendations are to ultracentrifuge such samples, which defeats the purpose of a POCT and may not be feasible in the acute emergency setting.…”

Section: Discussionmentioning

confidence: 90%

Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus

2021

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A 54-year-old woman with insulin-requiring type 2 diabetes mellitus presented with acute shortness of breath and drowsiness on a background of polydipsia, weakness and significant weight loss. One year ago, she had decided to stop her insulin and other medications and adopt lifestyle modifications instead. Initial emergency department (ED) blood samples were highly lipaemic and appeared strawberry pink. She was eventually diagnosed with diabetic ketoacidosis (DKA) with severe hypertriglyceridaemia, intubated for airway protection, and managed with fluid resuscitation and intravenous insulin to good effect. We share an uncommon DKA presentation at the ED. History was limited as the patient was drowsy and minimally communicative. Physical examination was unremarkable. Blood investigations were also delayed in view of the need for additional centrifugation. These contributed to a paucity of information in the acute setting and resulted in a diagnostic challenge.

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Section: Discussionmentioning

confidence: 90%

Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus

2021

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“…All the cases describing the management of severe hypertriglyceridemia with associated low measured bicarbonate levels have successfully used plasmapheresis. 2,3 However, it is expensive and may not always be available like in our case. We started insulin infusion for our patients while supplementing dextrose in maintenance uid.…”

Section: Discussionmentioning

confidence: 99%

“…Arterial blood gas (ABG) showed (pH 7.32, carbon dioxide partial pressure 44.4 mmHg, oxygen partial pressure 72. 3 Patients' lipase levels were normal, ketones were negative.…”

Section: Case Presentationmentioning

confidence: 96%

Severe Hypertriglyceridemia Causing Pseudo-acidosis: A Case Report

Gupta

Ojha

Temitope

2022

SN Compr. Clin. Med.

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Background: Pseudo hypobicarbonatemia is a rare phenomenon associated with spuriously low bicarbonate levels in the presence of elevated triglycerides (TG). TG's interfere with commonly used enzymatic assays in BMP, giving falsely low bicarbonate levels. It adds to the diagnostic dilemma and possible extensive workup to identify the cause. Previous case reports have used plasmapheresis in these settings. We report the successful use of insulin infusion in managing a case of pseudo-acidosis secondary to severely high TG levels.Case presentation: Our was a 53-year-old female who presented with complaints of progressive fatigue. Her bicarbonate was 5 mmol/L on workup, anion gap was 30 mmol/L, with elevated TG levels.(5904 mg/dL). Arterial blood gas analysis showed normal pH (7.32) and normal calculated bicarbonate. (22.8mEq/L) Insulin infusion was started along with adding feno brate and atorvastatin. TG levels decreased progressively to 509 mg/dL with an associated normalization of bicarbonate levels and aniongap acidosis on BMP. The patient was discharged on day 8 of her hospital stay. Conclusion:Hyper TG can lead to pseudo hypobicarbonatemia, presenting as pseudo anion gap metabolic acidosis. It is essential to correlate the lab ndings in the perspective of clinical ndings to avoid over-testing and clinical misdiagnosis. In addition, these patients can be managed safely with insulin infusion in resource-limited settings.

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“…However, the disparity between the serum bicarbonate levels from the two methods can be due to numerous reasons like dilution of plasma by heparin volume, venous CO2 accumulation due to tourniquet-induced stasis, and loss of CO2 from serum due to underfilling of vacuum collection, to mention a few [6]. Additionally, the enzymatic assay can interfere with wavelength measurement due to the presence of substances affecting serum turbidities such as bilirubin, hemoglobin, paraproteins, and lipids [11].…”

Section: Discussionmentioning

confidence: 99%

“…This incongruity in measurements of bicarbonate levels resolved after treatment with lipid-clearing agents [7]. Since then, many cases showing discord between ABG-calculated and autoanalyzer-measured values of serum bicarbonate, associated with hyperlipidemia, have been reported [1,9,[11][12][13].…”

Section: Discussionmentioning

confidence: 99%

A Case of Profound Hypertriglyceridemia Causing Pseudohypobicarbonatemia

Garg¹,

Chatterjee²

2023

Cureus

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The light-scattering effect of hypertriglyceridemia may interfere with the photometric analysis of the electrolytes, leading to errors in laboratory values. We present a case of erroneously low bicarbonate levels due to the presence of severe hypertriglyceridemia. A 49-year-old male was admitted for knee cellulitis. A comprehensive metabolic panel showed very low bicarbonate of <5 mmol/L, and an elevated anion gap of 26 mmol/L. The lactic acid, salicylic acid, ethanol, and methanol levels were normal. The lipid panel showed a remarkably high triglyceride level of 4846 mg/dL. An arterial blood gas (ABG) showed a normal pH of 7.39 and a bicarbonate level of 28 mmol/L, which was inconsistent with the metabolic acidosis seen in the blood test. The discrepancy between acidosis seen in the metabolic panel and ABG was explained by a lab error in the measured bicarbonate levels, which occurs in the presence of elevated triglyceride levels. Most laboratories use either an enzymatic/ photometric or an indirect ion-selective electrode method to measure bicarbonate. Hyperlipidemia interferes with photometric analysis due to its light-scattering effect. An ABG analyzer uses a direct ion-selective electrode method that is free of the errors of a photometric analyzer. Knowing about conditions like hypertriglyceridemia, which can interfere with the measurement of electrolytes, is important in everyday clinical medicine, as it can prevent unnecessary investigation and intervention.

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Pseudo-anion gap metabolic acidosis from severe hypertriglyceridemia corrected by plasma exchange

Cited by 11 publications

References 0 publications

Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus

Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus

Severe Hypertriglyceridemia Causing Pseudo-acidosis: A Case Report

A Case of Profound Hypertriglyceridemia Causing Pseudohypobicarbonatemia

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