Albumin makes up a majority of the anion gap (unmeasured anion protein). Hence in states of low albumin, an anion gap acidosis can falsely appear as a non-anion gap acidosis.
WHY? The albumin will be low – lowering the baseline gap and require much more unmeasured anions to exceed the cutoff of 12.
RULE OF THUMB: For every drop of 10g/L in albumin, drop the anion gap cutoff by 2.5-3mmol. (i.e with an albumin of 30, the anion gap cutoff is now 9)
References
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