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Kidney Week

Abstract: TH-PO176

A Unique Case of Metformin-Associated Lactic Acidosis

Session Information

Category: Trainee Case Report

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Author

  • Ahuja, Ashish C., UPMC Mercy, Pittsburgh, Pennsylvania, United States
Introduction

Metformin intoxication with lactic acidosis may develop in diabetic patients when the drug dose is inappropriate or its clearance is reduced. Comorbid medical conditions can make the diagnosis difficult, especially in the critical care unit. In this case, we present a patient who presented with AMS, found to have severe acidemia, with co-existing myxedema coma and urosepsis.

Case Description

A 62 year-old female presented for altered mental status. She takes Metformin 1 gm BID and recently started Liraglutide 1.2 mg daily. EMS found her at home, notably hypoxic, hypotensive and hypothermic. On arrival, she was found to have dysarthria but was able to convey a 2-week history of non-bloody diarrhea. Vitals revealed T 93.3C, BP 89/49, HR 79, RR 20, SpO2 100%. VBG showed severe acidemia with pH 6.97, pCO2 22, HCO2 6. Labs revealed lactic acid 13.5, AKI (72/13.6 from baseline 16/0.9), K 6.3, Mg 0.7, Ca 5.8, PO4 13.1, glucose 13. UA positive for infection. TSH found to be >500.00 with free T4 <0.2. She was given stress dose steroids followed by IV levothyroxine, ceftriaxone and bicarbonate infusion. One hour after arrival, her lactate rose to 15.6 with levophed at 0.4 mcg/kg/min. At this point, metformin intoxication was suspected and intermittent hemodialysis with dialysate flow rate of 300mL/min was initiated. Both blood pH and lactate level showed dramatic improvement after 6 hours of IHD. After a 14-hour IHD session, CHD was conducted through day 2. Urine culture grew Enterococcus faecalis and Aerococcus urinae and the patient received 3 days IV ceftriaxone. Levothyroxine 200mcg daily was started and steroids were stopped with pre-treatment AM cortisol level 62.1. Temporary dialysis catheter was removed on day 5 and the patient was discharged home on day 6. She was started on Repaglinide 0.5mg TID and asked to avoid metformin for the rest of her life.

Discussion

MALA is generally treated with supportive therapy, including initiation of RRT. In our case, we initiated a prolonged course of sustained low-efficiency dialysis (SLED) followed by CHD for one additional day to prevent rebound acidosis. This case is meant to highlight the importance of the early initiation of RRT and prevention of mortality. Additionally, it is important to manage comorbid conditions, such as myxedema coma and urosepsis, which may predispose patients to acute kidney injury and development of MALA.