Metformin-associated lactic acidosis (MALA): Is it an underestimated entity? A retrospective, single-center case series

IF 1.2 4区医学 Q3 UROLOGY & NEPHROLOGY

Hemodialysis International Pub Date : 2023-09-30 DOI:10.1111/hdi.13113

Susan Kim, Amara Sarwal, Xin Tan Yee, Sebastian A. Gandarillas Fraga, Vincent Campion, Isaiarasi Gnanasekaran

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Abstract

Introduction

Metformin is widely considered a first-line antiglycemic agent due to its cost-effectiveness and favorable adverse effect profile. However, its use is prohibited in patients with an estimated glomerular filtration rate <30 mL/min/1.73 m², due to the risk of potentially lethal metformin-associated lactic acidosis (MALA). We sought to evaluate MALA cases and outcomes at our institution.

Methods

In this observational, retrospective case series, we reviewed our EMR for all patients who had a metformin level drawn between January 2013 and May 2022 to identify individuals who met the diagnostic criteria for MALA. We evaluated risk factors for MALA, the relationship between metformin level, blood pH, serum bicarbonate, and lactate level and clinical outcomes of ventilator dependency, renal replacement therapy requirement, renal recovery in acute kidney injury (AKI) patients, and survival.

Findings

A total of 107 patients had metformin levels drawn, of which 19 patients met the diagnostic criteria for MALA. In our case series, MALA was primarily seen in AKI (15 patients) secondary to dehydration and sepsis, followed by end-stage renal disease (ESRD) (4 patients). Intubation was required in 17 patients, of whom 8 were successfully extubated after a mean duration of 14 days. Sixteen patients received renal replacement therapy (RRT). Intermittent hemodialysis (IHD) was performed in nine, continuous renal replacement therapy (CRRT) in four, and sequential therapy of IHD and CRRT in three patients. Seven patients, all in the AKI group (46.7%), died while all ESRD patients survived, accounting for an overall mortality rate of 36.8%. Among the eight surviving AKI patients, four had complete renal recovery with renal function returning to baseline, three had partial renal recovery, and one continued to require IHD at the time of discharge to a rehabilitation facility.

Discussion

MALA may be an underrecognized entity. A high level of clinical suspicion leading to prompt and aggressive treatment with RRT may improve mortality rates. Provider and patient education is of paramount importance for safe use of metformin.

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二甲双胍相关性乳酸酸中毒（MALA）：它是一个被低估的实体吗？一个回顾性的单中心病例系列。

引言：二甲双胍因其成本效益和良好的不良反应而被广泛认为是一线降糖药。然而，由于存在潜在致命的二甲双胍相关乳酸酸中毒（MALA）的风险，其在肾小球滤过率估计为2的患者中被禁止使用。我们试图评估我们机构的MALA病例和结果。方法：在这一观察性回顾性病例系列中，我们回顾了2013年1月至2022年5月期间所有二甲双胍水平的患者的EMR，以确定符合MALA诊断标准的个体。我们评估了MALA的危险因素，二甲双胍水平、血液pH、血清碳酸氢盐和乳酸水平与呼吸机依赖性的临床结果、肾脏替代治疗要求、急性肾损伤（AKI）患者的肾脏恢复和生存率之间的关系。研究结果：共有107名患者服用了二甲双胍，其中19名患者符合MALA的诊断标准。在我们的病例系列中，MALA主要见于继发于脱水和败血症的AKI（15名患者），其次是终末期肾病（ESRD）（4名患者）。17名患者需要插管，其中8名患者在平均14小时后成功拔管天。16名患者接受了肾脏替代治疗（RRT）。9名患者进行间歇性血液透析（IHD），4名患者进行连续肾脏替代治疗（CRRT），3名患者进行IHD和CRRT的序贯治疗。AKI组有7名患者（46.7%）死亡，ESRD患者全部存活，总死亡率为36.8%。在8名存活的AKI患者中，4名患者肾功能完全恢复，肾功能恢复到基线，3名患者肾部分恢复，1名患者出院时仍需IHD。讨论：MALA可能是一个被低估的实体。高度的临床怀疑导致RRT的及时和积极治疗可能会提高死亡率。提供者和患者的教育对于二甲双胍的安全使用至关重要。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Hemodialysis International UROLOGY & NEPHROLOGY-

CiteScore

2.50

自引率

0.00%

发文量

审稿时长

6-12 weeks

期刊介绍： Hemodialysis International was originally an annual publication containing the Proceedings of the International Symposium on Hemodialysis held in conjunction with the Annual Dialysis Conference. Since 2003, Hemodialysis International is published quarterly and contains original papers on clinical and experimental topics related to dialysis in addition to the Annual Dialysis Conference supplement. This journal is a must-have for nephrologists, nurses, and technicians worldwide. Quarterly issues of Hemodialysis International are included with your membership to the International Society for Hemodialysis. The journal contains original articles, review articles, and commentary to keep readers completely updated in the field of hemodialysis. Edited by international and multidisciplinary experts, Hemodialysis International disseminates critical information in the field.