Which results are abnormal in this comprehensive metabolic panel (CMP) with sodium 140 mmol/L, potassium 4.2 mmol/L, chloride 0.6 mmol/L, total CO₂ 22 mmol/L, blood urea nitrogen 43 mg/dL, creatinine 1.7 mg/dL, estimated glomerular filtration rate 43 mL/min/1.73 m², glucose 120 mg/dL, calcium 9.3 mg/dL, AST (aspartate aminotransferase) 41 U/L, ALT (alanine aminotransferase) 36 U/L, alkaline phosphatase 110 U/L, total bilirubin 0.5 mg/dL, albumin 3.9 g/dL, and total protein 6.1 g/dL?

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Abnormal Results in This Comprehensive Metabolic Panel

The abnormal values in this panel are: chloride (critically low at 0.6 mmol/L, likely a laboratory error), BUN (elevated at 43 mg/dL), creatinine (elevated at 1.7 mg/dL), GFR (reduced at 43 mL/min/1.73 m²), glucose (mildly elevated at 120 mg/dL), and AST (mildly elevated at 41 U/L).

Critical Finding: Chloride 0.6 mmol/L

This value is incompatible with life and represents a laboratory error requiring immediate verification. Normal chloride ranges from 96-106 mmol/L. A value this low would cause severe metabolic derangements and death 1. Contact the laboratory immediately to repeat this measurement - this is almost certainly a pre-analytical error (hemolysis, sample handling) or analytical interference 2.

Kidney Function Abnormalities (Most Clinically Significant)

Stage 3a Chronic Kidney Disease

The constellation of findings indicates CKD Stage G3a A1 3, 4:

  • Creatinine 1.7 mg/dL (normal: 0.6-1.2 mg/dL)
  • GFR 43 mL/min/1.73 m² (Stage 3a CKD defined as GFR 30-59 mL/min/1.73 m²) 4, 5
  • BUN 43 mg/dL (normal: 7-20 mg/dL)
  • BUN/Creatinine ratio = 25.3 (within normal range 10-20, slightly elevated)

This patient requires nephrology referral consideration if GFR drops below 30 mL/min/1.73 m² or if there are signs of rapidly progressive kidney disease 4. At GFR 43, the patient should be monitored 2-4 times yearly and screened for albuminuria to complete CKD staging 4.

Clinical Implications

The elevated BUN with creatinine suggests:

  • True reduction in kidney function (not just prerenal azotemia, given the BUN/Cr ratio)
  • Possible chronic kidney disease requiring further evaluation
  • Need to assess for proteinuria/albuminuria (not provided in this panel) 4, 6
  • Medication dosing adjustments required for renally-cleared drugs 7

Glucose Abnormality

Glucose 120 mg/dL is mildly elevated:

  • If fasting: indicates impaired fasting glucose (100-125 mg/dL range) or diabetes (≥126 mg/dL)
  • If non-fasting: may be normal
  • Requires correlation with HbA1c and fasting status 6

Given the presence of CKD, this patient may have diabetic kidney disease if diabetes is confirmed, which would require specific management with SGLT2 inhibitors and/or GLP-1 receptor agonists 6.

Liver Function Abnormality

AST 41 U/L is mildly elevated (normal: 29-33 U/L in men, 19-25 U/L in women) 8:

  • ALT 36 U/L is at the upper limit of normal or mildly elevated
  • AST/ALT ratio = 1.14 (ratio >2 suggests alcoholic liver disease; <1 suggests NAFLD) 9
  • This represents mild hepatocellular injury 8

The pattern suggests:

  • Possible non-alcoholic fatty liver disease (NAFLD), especially if metabolic syndrome present 8
  • Requires risk stratification with FIB-4 or NAFLD Fibrosis Score 10
  • Alkaline phosphatase, bilirubin, albumin, and total protein are all normal, making cholestatic disease or synthetic dysfunction unlikely

Normal Values

The following are within normal limits:

  • Sodium 140 mmol/L (normal: 135-145)
  • Potassium 4.2 mmol/L (normal: 3.5-5.0)
  • Total CO₂ 22 mmol/L (normal: 22-28)
  • Calcium 9.3 mg/dL (normal: 8.5-10.5)
  • Alkaline phosphatase 110 U/L (normal: 30-120)
  • Total bilirubin 0.5 mg/dL (normal: 0.1-1.2)
  • Albumin 3.9 g/dL (normal: 3.5-5.5)
  • Total protein 6.1 g/dL (normal: 6.0-8.3)

Immediate Actions Required

  1. Repeat chloride measurement immediately - current value is a laboratory error
  2. Obtain urinalysis with albumin-to-creatinine ratio to complete CKD staging 4
  3. Review medication list for necessary dose adjustments based on GFR 43 7
  4. Determine glucose fasting status and consider HbA1c
  5. Calculate FIB-4 score for liver fibrosis risk stratification 10
  6. Assess for metabolic syndrome criteria (hypertension, obesity, dyslipidemia) given CKD and possible NAFLD 8, 6

References

8
Guideline

acr appropriateness criteria® abnormal liver function tests.

Journal of the American College of Radiology, 2023

9
Guideline

alcoholic liver disease.

Hepatology, 2010

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