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Abstract: FR-PO228

Metformin-Associated Lactic Acidosis: A Mimicker of Acute Mesenteric Ischemia

Session Information

Category: Acute Kidney Injury

  • 103 AKI: Mechanisms


  • Hti Lar Seng, Nang San, New York City Health and Hospitals Jacobi, Bronx, New York, United States
  • Despradel, Luis C., New York City Health and Hospitals Jacobi, Bronx, New York, United States
  • Jim, Belinda, New York City Health and Hospitals Jacobi, Bronx, New York, United States

Metformin-associated lactic acidosis (MALA) is a rare life-threatening complication of metformin. Metformin is renally excreted with a major precipitating factor for MALA being acute kidney injury (AKI). The clinical presentation of MALA is similar to that of acute mesenteric ischemia though imaging is usually negative. Here we present a case of MALA masquerading as acute mesenteric ischemia and intra-abdominal sepsis.

Case Description

A 52-year-old female with a history of HTN, Type 2 DM on metformin, CKD of unclear baseline presented with vomiting, poor oral intake, and abdominal pain for 2 days with finger-stick glucose of 35 mg/dL. She denied fever, chills, urinary symptoms, diarrhea, or overdose of metformin. Her initial vitals were T 95.6 degree Fahrenheit, BP 171/96, HR 91, RR 16, and SpO2 100% on room air. The physical examination showed only dry oral mucosa. Laboratory values were significant for potassium 6.8 mEq/L, serum creatinine 7.9 mg/dL, blood urea nitrogen 61 mEq/L, glucose 49 mg/dL, bicarbonate 5.0 mEq/L, anion gap 45.9 mEq/L, venous blood gas with pH 7.0, PCO2 21 mmHg, lactate >17 mmol/L, white blood cell 17.7/nL. CT of the abdomen showed thickened small bowel loops and a questionable single loop of small bowel with pneumatosis. The patient was admitted for sepsis in the setting of presumed ischemic bowel. However, the surgery service discounted this diagnosis as they felt that there was no pneumatosis upon their review and that the thickened loops of bowel can be due to enteritis. She was empirically treated with intravenous piperacillin/tazobactam. Given AKI and severe lactic acidosis, a metformin level was sent. The patient was treated with 2 sessions of hemodialysis. When blood and urine cultures returned negative, antibiotics were discontinued. Her renal function improved to a serum creatinine of 1.6 mg/dL 2 weeks later, at which time the metformin level returned to be elevated at 27 mcg/ml (therapeutic level 1-2 mcg/ml).


Our case highlights that MALA can be confused with ischemic bowel on clinical presentation with abdominal pain, lactic acidemia and suggestive CT findings of pneumatosis intestinalis. Thus, high clinical suspicion and prompt treatment with renal replacement therapy is needed to avoid unnecessary surgery even without resulted metformin levels.