Non Anion Gap Metabolic Acidosis Treatment

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What is DIABETIC KETOACIDOSIS? What does DIABETIC KETOACIDOSIS mean? DIABETIC KETOACIDOSIS meaning - DIABETIC KETOACIDOSIS definition - DIABETIC KETOACIDOSIS explanation. Source: Wikipedia.org article, adapted under https://creativecommons.org/licenses/... license. SUBSCRIBE to our Google Earth flights channel - https://www.youtube.com/channel/UC6Uu... Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness. A person's breath may develop a specific smell. Onset of symptoms is usually rapid. In some cases people may not realize they previously had diabetes. DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances. Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids. DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies. DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine. The primary treatment of DKA is with intravenous fluids and insulin. Depending on the severity, insulin may be given intravenously or by injection under the skin. Usually potassium is also needed to prevent the development of low blood potassium. Throughout treatment blood sugar and potassium levels should be regularly checked. Antibiotics may be required in those with an underlying infection. In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended. Rates of DKA vary around the world. About 4% of people with type 1 diabetes in United Kingdom develop DKA a year, while in Malaysia the condition affects about 25% a year. DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost universally fatal. The risk of death with adequate and timely treatment is currently around 1–4%. Up to 1% of children with DKA develop a complication known as cerebral edema. The symptoms of an episode of diabetic ketoacidosis usually evolve over a period of about 24 hours. Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine production and abdominal pain that may be severe. Those who measure their glucose levels themselves may notice hyperglycemia (high blood sugar levels). In severe DKA, breathing becomes labored and of a deep, gasping character (a state referred to as "Kussmaul respiration"). The abdomen may be tender to the point that an acute abdomen may be suspected, such as acute pancreatitis, appendicitis or gastrointestinal perforation. Coffee ground vomiting (vomiting of altered blood) occurs in a minority of people; this tends to originate from erosion of the esophagus. In severe DKA, there may be confusion, lethargy, stupor or even coma (a marked decrease in the level of consciousness). On physical examination there is usually clinical evidence of dehydration, such as a dry mouth and decreased skin turgor. If the dehydration is profound enough to cause a decrease in the circulating blood volume, tachycardia (a fast heart rate) and low blood pressure may be observed. Often, a "ketotic" odor is present, which is often described as "fruity", often compared to the smell of pear drops whose scent is a ketone. If Kussmaul respiration is present, this is reflected in an increased respiratory rate.....

Mechanism Of Normochloremic And Hyperchloremic Acidosis In Diabetic Ketoacidosis

Oh M.S. · Carroll H.J. · Uribarri J. Man S. Oh, MD, Department of Medicine, State University of New York, Health Science Center at Brooklyn, Brooklyn, NY 11203 (USA) Continue reading >>

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  1. Marc

    Tom, how do you feel about the Atkins diet and its relation to hairloss, if any...

  2. Anonymous

    Here is a site that is interesting, regarding the debate of whether or not meat consumption is good for you or not, let me know what you think.

  3. Tom Hagerty

    I read the articles in the Weston A. Price site you gave a link to and agree with most of the content. Did you read the Myths & Truths About Nutrition segment? I usually don't like one-sentence answers to complex questions. Also, many of the sources given were over twenty years old. The site as a whole, though, presents good information, well documented.

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Anion gap usmle - anion gap metabolic acidosis normal anion gap metabolic acidosis

Metabolic Acidosis: Pathophysiology, Diagnosis And Management: Causes Of Metabolic Acidosis

Recommendations for the treatment of acute metabolic acidosis Gunnerson, K. J., Saul, M., He, S. & Kellum, J. Lactate versus non-lactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients. Crit. Care Med. 10, R22-R32 (2006). Eustace, J. A., Astor, B., Muntner, P M., Ikizler, T. A. & Coresh, J. Prevalence of acidosis and inflammation and their association with low serum albumin in chronic kidney disease. Kidney Int. 65, 1031-1040 (2004). Kraut, J. A. & Kurtz, I. Metabolic acidosis of CKD: diagnosis, clinical characteristics, and treatment. Am. J. Kidney Dis. 45, 978-993 (2005). Kalantar-Zadeh, K., Mehrotra, R., Fouque, D. & Kopple, J. D. Metabolic acidosis and malnutrition-inflammation complex syndrome in chronic renal failure. Semin. Dial. 17, 455-465 (2004). Kraut, J. A. & Kurtz, I. Controversies in the treatment of acute metabolic acidosis. NephSAP 5, 1-9 (2006). Cohen, R. M., Feldman, G. M. & Fernandez, P C. The balance of acid base and charge in health and disease. Kidney Int. 52, 287-293 (1997). Rodriguez-Soriano, J. & Vallo, A. Renal tubular acidosis. Pediatr. Nephrol. 4, 268-275 (1990). Wagner, C. A., Devuyst, O., Bourgeois, S. & Mohebbi, N. R Continue reading >>

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  1. chris

    6+ month update! With a lot more quotations! I know the Discourse discussion software isn't really suited to a wiki-style post like this, but at least I was upfront that I'd be updating it from the beginning.
    I ate nothing but my own custom version of soylent for a month before I discovered the ketogenic diet. That isn't documented here. I tried to make my soylent ketogenic for a week or so but failed rather miserably and soon switched to a non-soylent ketogenic diet. Thus this FAQ is largely about ketosis in general, with some personal notes of my experience in ketosis (no soylent). I'd find an official ketogenic version of soylent quite valuable.
    What is ketosis?
    Ketosis is a natural metabolic state wherein your body runs on ketones rather than glucose for energy. For most people it requires eating 50g or fewer carbohydrates per day, and only adequate levels of protein (your body can convert protein to glucose through gluconeogenesis, so overdoing protein will prevent a deep level of ketosis). High levels of fat are required to make up the calories (when maintaining weight) and provide ketones.
    Ketosis is also the same state your body enters when fasting or starving, which you can imagine there is an immense amount of research on. However the body is perfectly equipped for a regular ketogenic diet. The Inuit are an example of a culture who have been on a ketogenic diet for thousands of years
    16 . It's also been used to treat epilepsy
    3 with significant success. The induction phase of the Atkins diet is also ketogenic
    3 .
    Ketosis is also sometimes confused with ketoacidosis, which is a dangerous diabetic condition. This mistake seems easy to make among those familiar with ketoacidosis, so be wary.
    A primary risk for a ketogenic diet is that avoiding carbohydrates may make it difficult to receive all the required nutrients, this is obviously not a problem for soylent.
    The other main risk often cited is that too much protein can damage the kidneys. However, if your ketogenic diet is high on protein then you're doing it wrong. A ketogenic diet is carb-restricted, protein-adequate, high fat (once you reach weight maintenance). This risk is also easily mitigated with soylent. Note also that overdoing protein is not as great a risk as it appears even on a non-soylent ketogenic diet. Consider that fat is more calorie dense relative to either carbohydrates or protein (9:4 is the approximate ratio) thus the amount of calories from protein in meat is smaller than it appears.
    Decreased performance on a low carbohydrate diet is a myth perpetuated by junk studies of non-adapted individuals. Studies conducted after allowing sufficient adaptation time show equal, improved, or only marginally decreased performance. See The Art and Science of Low Carbohydrate Performance
    16 .
    Eating high levels of dietary fat is not a downside, see "fat loss" and "better heart health" under Benefits below.
    Entering ketosis is quick on 0 carb soylent (a few days I expect), however it takes time to become keto-adapted, or fat-adapted.
    Glucose in the form of glycogen requires quite a bit of water for storage in the body. This storage must be depleted before the body switches to burning ketones. As it depletes this storage the water comes with it. It's not uncommon to lose ~5lbs in the first week, half of which is water.
    It's said that during this time you can experience symptoms of lethargy, headaches, light-headedness, weakness, nausea, and so forth. This may seem like a natural consequence of switching primary energy sources but that is not the case. The symptoms are a result of depleted sodium levels due to the water loss. Supplement your diet with extra salt for a time to eliminate any deleterious symptoms during adaptation:
    When carbohydrates are restricted the body changes from retaining both water and salt to discarding them. [...] The loss of water and salt can reduce plasma volume and make you feel sluggish and compromise your ability to perform outdoors in the heat or in the weight room. As a result, some people get headaches and feel faint. This state of salt depletion causes a compensatory loss of potassium [...] The easy solution is to routinely take 1-2 grams of sodium per day in the form of 2 bouillon cubes (or home-made broth).
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 80-81). Beyond Obesity LLC. Kindle Edition.
    Should I cut carbs in one fell swoop or reduce them gradually?
    To date, no one has done a study with a large group of subjects to see which strategy yields a higher proportion making an effective transition into nutritional ketosis.
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 55). Beyond Obesity LLC. Kindle Edition.
    It is known that eliminating them all at once is tolerated quite well, so long as you supplement with sodium to compensate for the body's losses during adaptation. It also seems that reducing carbohydrates gradually may be a bit sketch as you could be in the gray area between running on glucose or ketones:
    What we do know is that it takes a couple of weeks to keto-adapt, and you don’t accomplish much towards that goal until you are making substantial amounts of ketones (i.e., eating less than 50 grams of carbs for most people). The other concern with easing into a low carb diet is that once you are eating less than the 150 grams of carb needed to feed your brain with glucose, but still more than the 50 gram threshold below which ketosis is dependably operating, your brain’s fuel supply becomes pretty tenuous.
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 55). Beyond Obesity LLC. Kindle Edition.
    I've read ranges between 1 and 8 weeks for adaptation, more commonly 2-4.
    Medium-chain triglycerides
    Olive oil is high in MCTs, and coconut oil even more so (~60%). They are digested and burned as energy easily and in that respect are similar to carbohydrates.
    They also generate more ketones than the long-chain triglycerides that compose the majority of dietary fat, which means ketosis can be maintained with less restrictive carbohydrate and protein intake.
    [...] MCT-induced ketone production may not be associated with the full spectrum of metabolic benefits associated with carbohydrate-restricted keto-adaptation. Thus, we do not encourage use of MCT oil. That said, however, neither do we discourage consuming foods that naturally contain MCT.
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 95). Beyond Obesity LLC. Kindle Edition.
    These are the commonly cited benefits, my experience/response follows.

    Significantly less hunger
    This was immensely obvious. After losing ~15 pounds and stabilizing at 10% body fat I seem to require more food (seems logical, since I have no major fat excess left to burn). While losing weight though I was astounded and shocked at my hunger reduction, it was a very unique experience.

    Fat loss without calorie counting
    I never counted calories, and I never exercised during my 2-3 month period where I lost ~15 pounds of fat (~16% body fat to 10%). It is true that I didn't eat unless hungry.
    It's commonly said that you'll lose weight when calories out > calories in. However this is merely a statement of the overall circumstance that will indeed exist on a fundamental physics level when fat loss occurs. The 1st law of thermodynamics, or energy conservation, does not specifically back up the external acts of eating calories or burning them during exercise any more than it backs up the notion of a purely internal change in fat storage or energy expenditure. It's an enormously common error in logic. To give some insight into this, consider that the equation contains no arrow of causality; it doesn't matter which side of the equation comes first. You can even transpose the variables like you learned in Algebra. It says with equal validity that if the fat mass is fixed, then exercising will cause hunger, or eating less will cause loss of energy. It doesn't say fat mass is fixed, but it doesn't say that it isn't fixed, it doesn't say anything about what's causing what, whether internal or external. The energy balance equation is about as useful as explaining that the reason a room is crowded is because "more people entered than left", it's obvious and not helpful, it reveals nothing about causation. If this is still unclear consider watching CrossFit - Gary Taubes: Why We Get Fat (Unabridged) Part 2, at 18 minutes and 21 seconds
    15 .
    Here's just one random little study on mice to show that such a thing is possible, emphasis mine.

    Mice on [the ketogenic diet] ate the same calories as mice on [the control diet] and [the high-fat high-carbohydrate diet], but weight dropped and stabilized at 85% initial weight, similar to [the calorie restricted diet]. This was consistent with increased energy expenditure seen in animals fed [the ketogenic diet] vs. those on [the control diet] and [the calorie restricted diet].
    A high-fat, ketogenic diet induces a unique metabolic state in mice

    Muscle-saving fat loss
    In Steve’s keto-adaptation experiments in cyclists[6], circulating [branched-chain amino acids (BCAA: leucine, isoleucine, and valine)] rose significantly during the ketogenic diet compared to their levels during the baseline high carbohydrate diet. This occurred despite the fact that both diets contained the same amounts of protein. BCAA oxidation typically increases in proportion to energy demands. In keto-adapted athletes, however, there appears to be less need for muscle to use BCAA as fuel [...] effectively demonstrated by Steve’s follow-up study showing that the higher blood leucine levels were a result of markedly decreased leucine oxidation.
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 33). Beyond Obesity LLC. Kindle Edition.
    6. Phinney SD, Bistrian BR, Evans WJ, Gervino E, Blackburn GL: The human metabolic response to chronic ketosis without caloric restriction: preservation of submaximal exercise capability with reduced carbohydrate oxidation. Metabolism 1983, 32(8):769-776.
    A major selling point for a ketogenic diet. I'm not a good candidate to demonstrate this, but my 15lbs weight loss took me from ~16% body fat to ~10% body fat, which seems pretty darn good to me. I did neither cardiovascular nor strength exercise.

    Balanced energy, stable blood sugar
    Body stores of fat fuel (typically >40, 000 Calories [kcal]) vastly exceed its maximum stores of carbohydrate fuel (~2,000 kcal).
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 7). Beyond Obesity LLC. Kindle Edition.
    [...] blood sugar can be well-maintained via metabolic processes such as gluconeogenesis without dietary carbohydrates in the keto-adapted human.
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 53). Beyond Obesity LLC. Kindle Edition.
    I absolutely notice much more balanced and sustained energy in myself. Without carbohydrates to influence blood sugar the body maintains it quite well.

    Less sleep required, better sleep, waking more refreshed, etc.
    Ordinarily when we sleep, as when fasting, ketones are elevated in the blood. I would postulate that when our body is highly adapted to burn fat and it's our primary source, more energy is available all night long, and waking is more natural. That's just a guess however, it could be an assortment of things. This was very apparent during my adaptation phase, but now it's less noticeable. Perhaps I don't experience the benefit without excess fat remaining to burn, or perhaps I've simply become used to it.

    Clearer skin
    I was skeptical of this one. There is very little research on acne and diet (I didn't say very little correlation). The science behind this is that the insulin response to elevated blood sugar levels from carbohydrates is too high in some people (hyperinsulinemia) and this "elicits a hormonal response that supports unregulated epithelial growth and increased sebum secretion".

    Ofiyeva, M. (2013). Adult Acne - The Connection Between Diet, Insulin, and Your Skin. [online] Retrieved from: http://www.dermaharmony.com/adultacne/dietinsulinandyourskin.aspx
    1 [Accessed: 5 Nov 2013].
    Here I am 6 months later still on a ketogenic diet 95% of the time, and I have to say that this has been the most profound change for me, even better than the fat loss. The improvement to my skin is so noticeable that this is the #1 reason I stay on this diet. Let me put things in perspective: I was on Accutane, the strongest acne treatment drug available, which worked briefly, I was then on Dan Kern's The Regimen
    5 for at least a few years (effective but spendy and an enormous hassle), and now I'm on nothing. I just spot treat with a tiny amount of benzoyl peroxide. The anti-inflammation property of this diet is insane. Before this diet If I wasn't doing a regular preventative treatment on the regimen my inflammation would escalate, and as it got worse it would get worse faster, think an exponential scale. Now with good sleep my issues are few. I only spot treat and everything heals in linear time. It's incredible.

    Better heart health!
    There is a misconception that a high fat diet will put you at the risk of heart disease. This is due to the common, and flawed thinking that ingesting fat must cause you to gain fat, in your blood and in your body. The reality is that when carbohydrates are restricted the body adapts to burning fat for energy so incredibly that you not only lose fat, but the levels of fat in your bloodstream drop as well. Your heart health markers improve in all areas.

    In two recently published studies we showed that a low carbohydrate, high fat diet significantly decreased circulating levels of saturated fat[23, 59].
    Phinney, Stephen; Volek, Jeff (2012-06-15). The Art and Science of Low Carbohydrate Performance (p. 72). Beyond Obesity LLC. Kindle Edition.

  2. cameronmalek

    I'm also on a ketogenic soylent and will report when I've been on only soylent for a week. Right now I'm adjusting the ingredients.

  3. ruipacheco

    This is where I'd say be very careful. Very very careful.

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Ever wondered what on earth the Anion Gap was all about? Yeah us neither. But when you've got yourself a metabolic acidosis, this is a good place to start. If you liked this, why not subscribe? And more importantly, let us know what you'd like to see us cover next.

The Anion Gap

The anion gap is a tool used to: Confirm that an acidosis is indeed metabolic Narrow down the cause of a metabolic acidosis Monitor the progress of treatment In a metabolic acidosis the anion gap is usually either ‘Normal’ or ‘High’. In rare cases it can be ‘low’, usually due to hypoalbuminaemia. An ABG machine will often give a print out of the anion gap, but it can also be useful to know how it is calculated. In blood, there are many cations and anions. However, the vast majority of the total number are potassium, sodium, chloride, or bicarbonate. The ‘anion’ gap is an artificial measure, which is calculated by subtracting the total number of anions (negatively charged ions – bicarbonate and chloride) from the total number of cations (sodium and potassium). Thus, the formula is: ([Na+]+ [K+]) –([Cl–]+ [HCO3–]) In reality, the concentration of potassium anions is negligible, and this often omitted. There are usually more measurable cations than anions, and thus a normal anion gap is value is positive. A normal value is usually 3-16, but may vary slightly depending on the technique used by the local laboratory. If the anion gap is <30, then there may not be Continue reading >>

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  1. Estes

    I feel like I just discovered a way to have access to my brain all day. I figured out that if I eat only protein (eggs, steak, ham, black coffee), I don't get foggy. I wanted to share this with anyone who needs a good day. Let me know if this works for you as well. I think I need my other food groups in the early evening but for now I want to try protein for breakfast and lunch. I took my D,B12,and Multi vitamins and still have a brain. This is a huge breakthrough for me.

  2. Ennis_TX

    Might be you react to other grains also, some celiacs also react to oats, and in rare cases all grains. Keto/paleo diet is a huge help I found, I mostly eat nuts, seeds, veggie protein powders, and egg whites myself with sides of veggies and sometimes a fig or small piece of dried fruit. NOTE I can not digest meats.

  3. Estes

    On March 18, 2017 at 10:13 PM, Ennis_TX said:
    Might be you react to other grains also, some celiacs also react to oats, and in rare cases all grains. Keto/paleo diet is a huge help I found, I mostly eat nuts, seeds, veggie protein powders, and egg whites myself with sides of veggies and sometimes a fig or small piece of dried fruit. NOTE I can not digest meats.
    I have been oat free from the start. I eat multi grain certified gluten-free chips, rice, and popcorn. It is likely one or all of those. I look forward to figuring out if it's all grains. I have been looking at Palio AIP and the Specific Carbohidrate diets. The main differences that I want to understand are sweet potatoes, eggs, and nuts.
    I love being able to function! Thank you for your response and insite.
    I have my 1 year celiac follow up on Friday.
    Also, my family continues to eat gluten. I do my best to avoid cross contamination.

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