High Anion Gap and Low Serum Chloride

Furiosus · Mar 9, 2017

I am a 49 year old male, currently on a regimen of Testosterone Cypionate and HCG. Last week I took a blood test, and I had some concerns.

My Anion Gap was extremely high, 26. The chart says I should be between 8 and 14.

My Serum Chloride was low, 23. The chart says I should be between 96 and 106.

I believe the Serum Chloride is used in the Anion Gap formula to figure out the acidity of my blood. Please correct me if I am wrong.

I do have diabetes, and understand that some of my medications can lead to metabolic acidosis, but before I panic, I wanted to discuss a variable that may, or may not, have affected my blood test.

I guess I don't follow instructions well. They said to fast, and not to have any food or caffeine before the test. I got up at 5 AM, and did not do the test until 11 AM. Between waking up, and the test, I had at least 5 cups of coffee. On my way to the Labcorp to get my blood draw, I got a cappuccino from Starbucks, and polished it off in the lobby.

Is it possible that the large concentration of caffeine screwed up my blood test? I read online that Anion Gap can be used to determine if somebody has caffeine caffeine toxicity. I feel great, and have no symptoms that I am aware of.

Thanks

Vince Carter · Mar 9, 2017

Fasting means what it says. You answered your own question. Now if this is the first test like this that your numbers have been out of range, you should retest and do it properly this time....fast at least 12 hours and have water ONLY.

Furiosus · Mar 9, 2017

Thanks. I know that acidosis can be caused from high blood sugars. I have been eating a paleo diet, and my blood sugars have running very low. In fact, since I started my TRT, I have become more sensitive to my medications, and have had to cut back due to low blood sugars.

johndoesmith · Mar 9, 2017

Furiosus said:
Thanks. I know that acidosis can be caused from high blood sugars. I have been eating a paleo diet, and my blood sugars have running very low. In fact, since I started my TRT, I have become more sensitive to my medications, and have had to cut back due to low blood sugars.

I don't think that lab result is accurate, post the full results if you want actual information.

I would not think 23 is compatible with life, you'd be seriously ill, if not dead if that was accurate IMO. I don't know for sure but I know electrolytes are critical to be kept in a specific range.

finkelet · Mar 10, 2017

You are exactly correct. One cannot live with a Cl of 23. All of your cells would lyse. That is either a incorrect test or you are misreading it. Post your chem panel and I'd be happy to analyze it for you. I read them for my patients daily.

finkelet · Mar 10, 2017

Is it possible you are reading the wrong line? Might it be your BUN you are looking at. That is often reported around the Cl and 23 would be a normal BUN.

johndoesmith · Mar 10, 2017

finkelet said:
You are exactly correct. One cannot live with a Cl of 23. All of your cells would lyse. That is either a incorrect test or you are misreading it. Post your chem panel and I'd be happy to analyze it for you. I read them for my patients daily.

I'm just trying to think whether hemolysis would cause a low Cl, but AFAIK that usually causes HIGH electrolytes due to cells rupturing.

I'm trying to think of how a lab would make an error ONLY with Cl.

I figured a Cl of 23 would be like a K of >8 or pH of <6.8 in terms of compatibility with life.

finkelet · Mar 10, 2017

It's amazing what lab errors can be made. Cl closley follows Na. This is because the main source of Cl in the body is from disassociated NaCl molecules. The main cause of low Cl and Na is hemodilution. Some root causes of that are Ingestion of a deadly amount of water, (I had a patient for of that last week. He was an inmate and he did this to kill himself. His Na was 120 and his Cl 85.) Addisions disease, CHF, or severe metabolic alkalosis can also lower Cl. But never to a level in the 20s.

Rhabdomyolysis would cause excessive K however it would not effect Cl.

On that note a K of 8 is a medical emergency that I see and treat not infrequently in critical care. It doesn't effect Cl marginally. There are 2 reasons for this. 1 Na and K are both cations. They are positively charged so they inversely follow each other. Cl is an anion or negatively charged. The major intracellurar anion is phosphate. Secondly to have such a massive shift of intracellurar and intravascular ions simply isn't possible. Your patient would be dead way befor that happened.

Sorry for the long reply but in a nutshel there is nothing that would cause a patient to have a Cl as low as 23 with the exception of a fatal transfusion of sterile water or D5W. Like 30 liters worth. Considering that our average blood volume is around 6L (100kg patient) you see the impossibility of this.

johndoesmith · Mar 10, 2017

finkelet said:
It's amazing what lab errors can be made. Cl closley follows Na. This is because the main source of Cl in the body is from disassociated NaCl molecules. The main cause of low Cl and Na is hemodilution. Some root causes of that are Ingestion of a deadly amount of water, (I had a patient for of that last week. He was an inmate and he did this to kill himself. His Na was 120 and his Cl 85.) Addisions disease, CHF, or severe metabolic alkalosis can also lower Cl. But never to a level in the 20s.

Rhabdomyolysis would cause excessive K however it would not effect Cl.

On that note a K of 8 is a medical emergency that I see and treat not infrequently in critical care. It doesn't effect Cl marginally. There are 2 reasons for this. 1 Na and K are both cations. They are positively charged so they inversely follow each other. Cl is an anion or negatively charged. The major intracellurar anion is phosphate. Secondly to have such a massive shift of intracellurar and intravascular ions simply isn't possible. Your patient would be dead way befor that happened.

Sorry for the long reply but in a nutshel there is nothing that would cause a patient to have a Cl as low as 23 with the exception of a fatal transfusion of sterile water or D5W. Like 30 liters worth. Considering that our average blood volume is around 6L (100kg patient) you see the impossibility of this.

I am impressed with your clinical knowledge!

I of course did not mean that K would impact Cl, I just know that high K levels are incompatible with life, much like a 23 Cl level.

I did a bit of searching for hypochloremia and I only found information about 45-60 or so, nothing near 23. I agree with you, it is impossible. Either OP misread the report, or a lab error.

I do think that CO2 is right next to Cl on a CMP so it's possible he misread his CO2 as Cl.

finkelet · Mar 10, 2017

Co is also very possible and 23 would be a reasonable Co number.

Thanks for the words. I've had an interesting career and a variety of places to learn. My education is in nuclear engineering so chemistry in general is pretty comfortable. I left that to work as an EMT went back to college to earn my paramedic licensure, worked up to critical care flight medicine. I now work in organ donation where I clinical manage brain dead (heart beating) organ donors in the ICU setting treating them to maximize organ function. I see a lot of crazy metabolic states with those patients.

But it's amazing how much I've learned both here and through my own journey (which is still starting) with TRT.

Look forward to continued learning with all of you.

High Anion Gap and Low Serum Chloride

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