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A 77-year-old male, with stable chronic kidney disease stage 3, type 2 diabetes and peripheral vasculopathy, was admitted to our hospital for treatment of a badly healing diabetic ulcer on the right hallux. Empirical therapy with intravenous flucloxacillin was started. A wound swab subsequently showed growth of methicillin sensitive Staphylococcus aureus. His maintenance therapy, consisting of metformin, low dose aspirin and candesartan, was continued. Delayed healing prompted a vascular work-up, followed by percutaneous transluminal angioplasty of the right external iliac artery. Despite these interventions, the ulcer deteriorated and 2 weeks later the right hallux had to be amputated. During the ensuing 2 weeks, the surgical wound healed reasonably well, but the patient’s general condition degraded with progressive nausea and anorexia. Physical examination revealed discrete abdominal tenderness and diminished bowel sounds. Biochemistry showed no major inflammation, but serum creatinine had risen from a baseline value of 1.3–2.0 mg/dL, which led to the cessation of metformin and candesartan. His glycaemia remained well controlled. During the next 24 h, he became hypotensive (70/30 mmHg) and started to hyperventilate vigorously. He was started on intravenous (IV) fluids and was transferred to the intensive care unit (ICU). Results of blood samples taken upon admission to the ICU, and additional blood and urine tests, obtained 12 h later, are summarized in Table 1. An abdominal computed tomography-angioscan was performed with iso-osmolar contrast after intravenous administration of isotonic NaHCO3 and allowed to rule out intestinal ischaemia. His blood pressure ameliorated slightly and diuresis remained well preserved.

High anion gap metabolic acidosis: use the proper acronym, discard the red herrings and thou shall find the culprit