ASN's Mission

ASN leads the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge, and advocating for the highest quality care for patients.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005


The Latest on Twitter

Kidney Week

Abstract: TH-PO178

Survival After Severe Metformin-Associated Lactic Acidosis (MALA) with Aggressive Dialysis and Massive Bicarbonate Administration

Session Information

Category: Trainee Case Report

  • 902 Fluid and Electrolytes: Clinical


  • Agarwal, Neil Kumar, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
  • Plotskaya, Natalia, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
  • Goldman, Jesse M., Drexel University College of Medicine, Philadelphia, Pennsylvania, United States

MALA is a severe condition affecting fewer than 1 in 10,000 people. Mortality is often above 20%. We present a case of intentional metformin overdose surviving after combined dialysis modality use and massive parenteral sodium bicarbonate (NaHCO3) administration.

Case Description

52-year-old male with PMH: HIV on HAART, DM, HTN, Hep C and cocaine use who intentionally ingested 60g Metformin in the ED without staff knowledge. 12 hours later, patient was found lethargic with a blood glucose of <10 mg/dl. Arterial blood gas: pH 7.02, PaCO2 23.3mmHg, PaO2 128mmHg. Serum chemistry: Na 144mmol/L, K 3.8mmol/L, Cl 98mmol/L, Cr 1.57mg/dL, HCO3 12mmol/L, ALT 64unit/L, AST 74unit/L, AG 32, lactic acid >25.0 mmol/L. Patient was intubated, hyperventilated and begun on 3 vasopressors for hypotension. No GI lavage performed. Next, simultaneously started 150meq NaHCO3 infusion at 150mL/hr and intermittent HD (IHD) for 3 hours with O200, Qb 400mL/min and Qd 800mL/min, Bicarb bath: 40meq/L. He was transitioned directly onto CVVHD using Prismasate 4/2.5 with Qb 300mL/min and Qd 3L/hr, later increased to 5L/hr. The NaHCO3 infusion was increased to 600mL/hr due to persistent pH <7.2. An additional 50meq of NaHCO3 was added to each dialysate bag. The patient’s pH remained <7.2 throughout renal replacement therapy (RRT). A Metformin level prior to any RRT was 67mcg/dL. 11.5 hours after IHD and CVVHD initiation, the Metformin level fell to 23mcg/dL. CVVHD was continued due to anuria and high fluid requirements. 24 hours after initiating RRT, pH and HCO3 improved to 7.35 and 23mmol/L, respectively. Serum lactic acid fell from >25mmol/L to 13.7mmol/L. The patient was extubated, weaned off vasopressors and discharged after delayed renal recovery on hospital day 25 with Cr 3.41mg/dl.


Metformin (molecular weight 129, minimal protein binding) is rapidly distributed into tissue compartments. The large volume of distribution (300-1000L) prevents complete clearance by conventional IHD resulting in prolonged toxicity. In our case, 11,780meq of NaHCO3 was given IV over 24-hours. He also received additional NaHCO3 from 3 hrs of IHD in a 40meq/L dialysate bath followed by CVVHD using 32meq/L bags, later increased to 42meq/L. High UF rate with RRT allowed massive delivery of IV NaHCO3 in combo with dialysis for aggressive treatment of MALA.