There are three main causes of AG enlargement metabolic acidosis: 1. HCO3- is consumed due to neutralization of organic acids and [HCO3-] is reduced. 2. Increased acid production: starvation, diabetes, etc. due to massive decomposition of body fat ketone bodies are generated; hypoxia, shock, cardiac and respiratory arrest, etc. make aerobic oxidation impaired and anaerobic enzymes increase lactic acid production. Ketone bodies and lactic acid content can increase the concentration of organic acid anions in the blood and increase AG, and HCO3- in the plasma is consumed to neutralize these acids, causing increased AG metabolic acidosis. 3. Decreased acid excretion: Increased AG metabolic acidosis caused by renal dysfunction is seen in severe renal failure. At this time, in addition to the reduction of H+ secretion by renal tubular epithelial cells, the glomerular filtration rate is significantly reduced. The most important thing in the management of metabolic acidosis with increased AG is to look at the cause, such as diabetic ketoacidosis, which requires rehydration and insulin. control of blood glucose. Sometimes the acidosis is so severe that treatment with hemodialysis can be used.