27-year-old homeless man with a history of alcohol abuse is brought to
the emergency department obtunded. On examination, he is a disheveled
male with rapid deep respirations. His blood pressure is 120/70 mm Hg,
pulse 120 beats/min, and respiratory rate 36 breaths/min. His sclerae
are anicteric. His pupils are 5 mm and responsive. Disc margins are
sharp. Chest and cardiovascular examination are without abnormalities.
An arterial blood gas measurement demonstrates a
Po2 120 mm Hg, Pco2 18
mm Hg, and pH 7.1. Laboratory tests reveal the following: sodium
138 mEq/L (138 mmol/L), potassium 4.0 mEq/L (4.0 mmol/L), chloride
96 mEq/L (96 mmol/L), bicarbonate 10 mEq/L (10 mmol/L), glucose 80
mg/dL (4.4 mmol/L), and blood urea nitrogen 4 mg/dL (1.1 mmol/L). Serum
osmolality is 346 mOsm/kg (346 mmol/kg). Urinalysis shows numerous
calcium oxalate crystals. This patient’s acidosis is probably
secondary to which of the following?