From the Guidelines
Lactate clearance is crucial in patients with cirrhosis, and the current recommendation is to use a model incorporating MELD and lactate (MELD-LA) for prognosis, as it outperforms other scores in predicting mortality 1. The management of lactate clearance in cirrhosis involves identifying and treating the underlying cause of hyperlactatemia, providing supportive care, and monitoring lactate levels closely.
- Initial management should focus on hemodynamic stabilization with judicious fluid resuscitation, avoiding volume overload.
- Vasopressors, such as norepinephrine, may be necessary if fluid resuscitation is insufficient.
- Infection should be treated promptly with broad-spectrum antibiotics.
- Continuous lactate monitoring is recommended, with a focus on interpreting lactate trends rather than absolute values. Key considerations in lactate clearance for cirrhotic patients include:
- Impaired hepatic metabolism leading to slower lactate clearance
- The importance of addressing precipitating factors such as gastrointestinal bleeding, sepsis, or respiratory failure
- The use of scores like MELD-LA to predict mortality and guide management decisions, as supported by recent studies 1.
From the Research
Lactate Clearance in Cirrhosis
- Lactate levels and lactate clearance are known predictors of outcome in critically ill patients with cirrhosis 2.
- Elevated serum lactate levels are associated with a higher mortality rate in patients with cirrhosis and acute kidney injury 3.
- Initial lactate levels and lactate at 6 hours were significantly higher in cirrhosis patients than in non-cirrhosis patients with septic shock 4.
- Lactate clearance had significant predictive ability for 28-day mortality in patients with elevated serum lactate ≥5 mmol/L 2.
Recommendations for Lactate Clearance
- Admission lactate and 12-hour lactate clearance (in patients with admission lactate ≥5 mmol/L) were identified as significant predictors of 1-year mortality, independent of Chronic Liver Failure Consortium acute-on-chronic liver failure score (CLIF-C ACLFs) 2.
- A lactate-adjusted CLIF-C ACLFs was developed (CLIF-C ACLFsLact), which performed significantly better than the original CLIF-C ACLFs in prediction of 28-day mortality in the derivation and validation cohort 2.
- Utilizing lactate >2 mmol/L in the definition of septic shock, as well as a target mean arterial pressure of >65 mmHg during resuscitation in patients with cirrhosis, is supported by recent findings 5.
Clinical Implications
- Lactate levels and lactate clearance should be monitored in critically ill patients with cirrhosis to predict outcome and guide management 2, 3, 4.
- Elevated serum lactate levels should be part of rapid diagnosis and initiation of therapy to improve clinical outcome in patients with cirrhosis and acute kidney injury 3.
- The use of lactulose, terlipressin, and other therapies may be beneficial in managing complications of cirrhosis, including hepatic encephalopathy and hepatorenal syndrome 6.