Abstract: PUB014
Fulminant Metformin-Associated Lactic Acidosis Complicated by RIFLE III AKI in a Patient with Cancer
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Karamyan, Manya, Yerevan State Medical University Named after Mkhitar Heratsi, Yerevan, Armenia
- Minasyan, Armine, Yerevan State Medical University Named after Mkhitar Heratsi, Yerevan, Armenia
- Stepanyan, Mariam D., Yerevan State Medical University Named after Mkhitar Heratsi, Yerevan, Armenia
Introduction
Metformin-associated lactic acidosis (MALA) is a rare but life-threatening metabolic complication that occurs most commonly in the setting of impaired renal clearance. Patients with malignancy are particularly vulnerable because of reduced physiologic reserve, fluctuating kidney function, and increased susceptibility to acute illness.
Case Description
A 68-year-old woman with type 2 diabetes mellitus and recently treated breast cancer (pT2N0M0) presented with vomiting, oliguria, progressive weakness, and altered mental status. Laboratory evaluation demonstrated severe high anion gap metabolic acidosis with pH 7.0, bicarbonate 2.5 mmol/L, lactate 8.66 mmol/L, potassium 8.54 mmol/L, and severe acute kidney injury consistent with RIFLE stage III. Serum creatinine at admission was 800 µmol/L. Metformin-associated lactic acidosis was suspected in the setting of acute kidney injury with impaired metformin clearance.
Metformin was immediately discontinued, and the patient was transferred to the intensive care unit. Urgent intermittent hemodialysis was initiated because of severe acidosis, hyperkalemia, and anuric kidney failure. Despite three hemodialysis sessions and aggressive supportive management, severe metabolic derangements persisted with progressive respiratory failure and hemodynamic instability, reflecting refractory systemic metabolic dysfunction. Following renal replacement therapy and supportive care, kidney function partially recovered, with serum creatinine decreasing to 137 µmol/L at discharge.
Discussion
This case highlights the rapid progression and high mortality risk of MALA in oncologic patients with acute kidney injury. Reduced renal clearance likely resulted in metformin accumulation, mitochondrial dysfunction, impaired oxidative phosphorylation, and severe lactate overproduction. The coexistence of advanced AKI and MALA may create a self-perpetuating cycle of metabolic failure that can remain refractory despite timely renal replacement therapy. Early recognition of MALA is essential in metformin-treated patients presenting with unexplained high anion gap metabolic acidosis, particularly in vulnerable oncologic populations during periods of acute illness or physiologic stress.
Acknowledgment
The authors acknowledge the intensive care and hemodialysis teams of the National Center of Oncology for their contribution to patient management.