From the Guidelines
Extracorporeal treatment with bicarbonate-buffered replacement fluids is recommended for patients with lactic acidosis, as it is preferred over lactate-buffered fluids in these cases. When considering extracorporeal treatment for lactic acidosis, it is essential to prioritize the use of bicarbonate as a buffer, as lactate can worsen acidosis in patients with lactic acidosis or liver failure 1. The use of bicarbonate-buffered replacement fluids is supported by the fact that both lactate and bicarbonate can correct metabolic acidosis in most CRRT patients, but bicarbonate is preferred in patients with lactic acidosis and/or liver failure (grade C) 1.
Key Considerations for Extracorporeal Treatment
- Bicarbonate-buffered replacement fluids should be used in patients with lactic acidosis
- Lactate-buffered fluids can worsen acidosis in patients with lactic acidosis or liver failure 1
- The choice of buffer should be based on the individual patient's condition, with bicarbonate preferred in cases of lactic acidosis or liver failure
- Fluid management is critical, and volume overload should be avoided, especially in patients with acute lung injury (grade C) 1
Treatment Approach
- Continuous renal replacement therapy (CRRT) or hemodialysis can be used to treat lactic acidosis
- Treatment should be initiated promptly, with the goal of reducing lactate levels and normalizing pH
- Hemodynamic monitoring is crucial during treatment, as these patients are often unstable and may require vasopressor support
- Electrolyte replacement, particularly calcium and potassium, should be monitored closely during treatment as levels can fluctuate significantly 1
From the FDA Drug Label
In metformin hydrochloride tablets treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin (metformin hydrochloride is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions). The recommended extracorporeal treatment for lactic acidosis is hemodialysis, which can help correct the acidosis and remove accumulated metformin 2.
- Hemodialysis is recommended in patients with a diagnosis or strong suspicion of lactic acidosis.
- It can help remove accumulated metformin with a clearance of up to 170 mL/min under good hemodynamic conditions.
From the Research
Extracorporeal Treatment for Lactic Acidosis
- Extracorporeal treatment, such as continuous renal replacement therapy (CRRT), has been used to treat lactic acidosis, particularly in cases of metformin-associated lactic acidosis (MALA) 3, 4.
- CRRT has been shown to efficiently control metabolic acidosis and eliminate metformin in patients with MALA 3.
- The use of CRRT in patients with severe lactic acidosis has been associated with favorable outcomes, including rapid correction of acid-base balance and renal function 4, 5.
- However, a retrospective study found that patients who received renal replacement therapy (RRT) for severe lactic acidosis had higher odds of mortality compared to those who did not receive RRT, even after adjustment for propensity to start RRT 6.
Types of Extracorporeal Treatment
- Continuous venovenous hemofiltration (CVVH) and hemodiafiltration (CVVHDF) are types of CRRT that have been used to treat lactic acidosis 3, 4.
- CVVHDF has been shown to correct acidosis and remove lactate and metformin without the risk of hypernatremia or fluid overload 4.
- Hemodialysis has also been used to treat lactic acidosis, particularly in cases of metformin overdose 5.
Factors Influencing the Decision to Start Extracorporeal Treatment
- The decision to start RRT in patients with severe lactic acidosis is influenced by factors such as lactate level, SOFA renal and cardio score, and the presence of underlying conditions such as renal failure 6.
- The propensity to receive RRT is related to the severity of the condition and the presence of organ dysfunction 6.