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Abstract: SA-PO499

MALA: Surviving Extreme Metformin Toxicity

Session Information

Category: Fluid‚ Electrolyte‚ and Acid-Base Disorders

  • 1002 Fluid‚ Electrolyte‚ and Acid-Base Disorders: Clinical


  • Chowdhury, Raad B., UPMC, Pittsburgh, Pennsylvania, United States
  • Palevsky, Paul M., University of Pittsburgh, Pittsburgh, Pennsylvania, United States

Metformin (MET) induced lactic acidosis (MALA) is a potentially life-threatening complication of MET associated with decreased kidney function characterized by a profound type B lactic acidosis with vasoplegia and circulatory collapse. Management of requires drug removal using kidney replacement therapy. In 2019, close to 90 million prescriptions of metformin were filled1. MALA is rare in absence of kidney dysfunction and MET is contraindicated at eGFR < 30 mL/min/1.73 m2. MALA. Serum MET levels are important in distinguishing these cases from other causes of lactic acidosis. We describe a case of MALA with one of the highest serum levels reported, in a patient with no prior history of renal disease.

Case Description

A 33-year-old female with unknown past medical history presented as a transfer from an outside hospital after ingestion of 90 grams of MET. On initial presentation her lactate was 11 mmol/L, with rapid clinical decompensation and minimal responsiveness. On transfer, her pH was 6.86, HCO3- 7 mmol/L, AG 24 mmol/L, lactate 18.3 mmol/l, BUN 18 mg/dl, Cr. 1.1 mg/dl, K+ 5.1 mmol/l, and Posm 348 mOsm/kg. High flux hemodialysis (HD) was initiated for presumed MALA while awaiting pre-HD MET levels. She received hemodialysis for 47.25 hours until her lactate was <3 mmol/L and pH >7.35. Her admission MET level was ultimately reported as 470 mcg/ml. She was discharged from the hospital after 40 days and was HD independent.


We describe a young female with no prior history of kidney disease who developed MALA associated with one of the highest MET levels reported after massive ingestion who survived after prolonged extracorporeal drug removal. In a systematic review by Yeh et al2, the highest reported MET level was 380.0 mcg/ml with a correlation between levels and ingested drug, consistent with our case. In our review of the literature MET levels of >200 mcg/mL were generally fatal. Although MALA is commonly associated with decreased kidney function, this case illustrates that massive MET ingestion can cause MALA independent of other risk factors including presence of kidney disease. In conclusion, we report a case of MALA with a substantial ingestion burden and arguably one of the highest reported levels of metformin who survived after early and prolonged hemodialysis.