A less successful (and admittedly less useful) mnemonic exists for non-anion gap metabolic acidoses (NAGMA), which I learned as a resident. It’s “HARDUP”, which stands for the following:
H = hyperalimentation (e.g., starting TPN).
A = acetazolamide use.
R = renal tubular acidosis (Type I = distal; Type II = proximal; Type IV = hyporeninemic hypoaldosteronism.
D = diarrhea
U = uretosigmoid fistula (because the colon will waste bicarbonate).
P = pancreatic fistula (because of alkali loss–the pancreas secretes a bicarbonate-rich fluid).
Practically speaking however, the two main causes you really have to remember for NAGMA are DIARRHEA or RENAL TUBULAR ACIDOSIS, which 90% of the time you can distinguish between based on the history alone. Another way to think about the differential diagnosis of NAGMA is to ask whether or not there is GI LOSS or RENAL LOSS of bicarbonate. If the history does not provide an obvious explanation, one can distinguish between GI versus renal bicarbonate losses by determining the urine anion gap (urine AG = urine Na + urine K – urine Cl), where a positive value indicates renal bicarbonate loss whereas a largely negative value indicates extra-renal bicarbonate loss.
USED CRAP – SINCE MOST OF THE CAUSES ARE GASTROINTESTINAL IN ORIGIN -URETEROENTEROSTOMY, SMALL BOWEL FISTULA, EXTRA CLHORIDE, DIARRHEA, CARBONIC ANHYDRASE INHIBITORS, RENAL TUBULAR ACIDOSIS, ADDISONS, LOW ALBUMIN, PANCREATIC FISTULA
I have to make a correction here if I may.
A positive UAG does not indicate renal bicarb losses at all.
It indicates low amount of urinary ammonium excretion (as in distal RTA & type 4 RTA).
Renal bicarbonate occurs in proximal RTA but in that particular situation, UAG is not helpful.
Mnemonic I use for NAGMA is "ABCD"
– Bicarb loss (Renal or GI)
– Chloride excess (eg normal saline)
– Drugs eg acetazolamide
It seems to cover all the options people have mentioned previously…
Aggressive saline = Hyperchloremia
as a non-renal fellow from durham–thanks for posting!!
What about DURHAM?
what about aggressive fluid resuscitation w/ NS, its anoher cause of NAGPMA
thanks for posting..
My mnemonics for NAGMA is FORD
What about Aggresive Saline recus as a cause? You could add an "S" on the end to make HARDUPS (Saline recus)?
RTA (type 3) accounts for aldo
I still like "HARDUP". When I was learning different languages as a kid… the dirty words and phrases always "came quick" and stuck!
What about Addison's? I thought that could cause NAGMA as the lack of cortisol/aldosterone leads to renal sodium wasting but retention of H+ and K+ ions. I can't remember the exact transporters or ion channels involved because I'm not a renal physician (but I did know at one time!). The mnemonic I use is for NAGMA is "DARA" – Diarrhoea (or variants thereof, eg. fistulae), Acetazolamide, Renal tubular acidosis, Addison's. Any thoughts?