Successful treatment of metformin-associated lactic acidosis in a hemodialysis patient

  • Miura Rei
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Kajiwara Kengo
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Yagi Yoshitaka
    Department of Diabetes and Endocrinology, National Hospital Organization Kumamoto Medical Center
  • Sakamoto Wakana
    Department of Diabetes and Endocrinology, National Hospital Organization Kumamoto Medical Center
  • Serikawa Ami
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Nishiyama Keiko
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Yoshii Ryuichi
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Nishiguti Yoshihiko
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Yamamoto Sayuri
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Nakamura Tomofumi
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Kajiwara Nao
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Fujimoto Kaori
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Onoue Tomoaki
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Tomita Masao
    Department of Nephrology, National Hospital Organization Kumamoto Medical Center
  • Mukoyama Masashi
    Department of Nephrology, Graduate School of Medical Sciences, Kumamoto University

Bibliographic Information

Other Title
  • メトホルミン内服による乳酸アシドーシスに対し緊急透析にて救命しえた1例
  • 症例報告 メトホルミン内服による乳酸アシドーシスに対し緊急透析にて救命しえた1例
  • ショウレイ ホウコク メトホルミン ナイフク ニ ヨル ニュウサン アシドーシス ニ タイシ キンキュウ トウセキ ニテ キュウメイ シエタ 1レイ

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Abstract

<p>The number of diabetic patients is increasing in Japan. Metformin is an antidiabetic agent, which suppresses gluconeogenesis. Unlike other antidiabetic agents, metformin reduces insulin resistance and is not strongly associated with hypoglycemia or weight gain. Furthermore, clinical studies have demonstrated that it is effective against cardiovascular disease. Given its effects and affordability, metformin is a commonly used oral hypoglycemic drug. However, its use is associated with lactic acidosis in extremely rare cases. While lactic acidosis is rare in metformin-treated patients, it requires immediate attention since it can be lethal. We report a case of severe lactic acidosis (pH: 7.0; lactate: >20 mmol/L, potassium [K]: 6.1 mEq/L, creatinine: 2.4 mg/dL, estimated glomerular filtration rate: 23.8 mL/min/1.7 m2) in a 53-year-old male diabetic patient who was taking metformin. On admission, his white blood cell count, C-reactive protein level, and procalcitonin level were elevated, and he was diagnosed with metformin-associated lactic acidosis (MALA) caused by an infection. Since his symptoms did not improve despite supportive care, he was switched to 2-hour hemodialysis using a blood pump (200 mL/min), dialysate pump (500 mL/min), and an APS18MD membrane (polysulfone; Asahikasei Kuraray Medical, Tokyo). After the hemodialysis, his condition improved markedly (pH: 7.4; lactate: 5.2 mmol/L, K: 4.7 mEq/L). Supportive care and extracorporeal circulation are the only treatment options for MALA. Extracorporeal circulation effectively removes metformin from the body. Furthermore, it rapidly controls acidosis, hyperlactatemia, and electrolyte imbalances and compensates for impaired kidney function. Patients with lactate levels of >20 mmol/L and pH values of <7.0 are indicated for extracorporeal circulation, until they achieve a lactate level of <3.0 mmol/L and a pH value of >7.35. In Japan, where dialysis is commonly employed, extracorporeal circulation is a highly safe treatment. Since MALA is a life-threatening disease, extracorporeal circulation should be used to treat high-risk patients with the condition whenever possible.</p>

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