From the Guidelines
Dialysis can be an effective treatment for lactic acidosis, particularly in severe cases or when the underlying cause cannot be immediately addressed, with bicarbonate preferred as a buffer in patients with lactic acidosis or liver failure 1. When considering dialysis for lactic acidosis, it's crucial to understand that both lactate and bicarbonate can correct metabolic acidosis in most continuous renal replacement therapy (CRRT) patients, but bicarbonate is the preferred choice for patients with lactic acidosis or liver failure due to the potential worsening of acidosis with lactate use 1. Key points to consider include:
- The use of dialysis should be adjunctive, focusing on addressing the underlying cause of lactic acidosis, such as improving tissue oxygenation or treating infection.
- Both hemodialysis and CRRT can be effective, with the choice depending on the patient's hemodynamic stability and other clinical factors.
- In patients with renal failure, dialysis is particularly valuable for removing excess lactate and hydrogen ions from the bloodstream.
- Supportive measures like intravenous fluids, vasopressors, and in some cases sodium bicarbonate may be used alongside dialysis to manage the condition effectively.
- It's essential to avoid supra-physiologic concentrations of glucose in dialysis or substitution fluids to prevent hyperglycemia and to consider the fluid composition and management carefully to avoid worsening the patient's condition 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). Metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful for removal of accumulated drug from patients in whom metformin overdosage is suspected.
Dialysis can help treat lactic acidosis by removing accumulated metformin and correcting the acidosis, as stated in the drug labels of metformin hydrochloride tablets 2 and 2. Hemodialysis is recommended in patients with a diagnosis or strong suspicion of lactic acidosis.
From the Research
Treatment of Lactic Acidosis with Dialysis
- Dialysis can be an effective treatment for lactic acidosis, particularly in cases of metformin-associated lactic acidosis (MALA) 3, 4, 5, 6.
- Studies have shown that both peritoneal dialysis and hemodialysis can be used to treat lactic acidosis, with some cases requiring prolonged dialysis 3, 4, 6.
- The use of dialysis in combination with other treatments, such as sodium bicarbonate and supportive care, can improve outcomes in patients with lactic acidosis 4, 7, 5.
Efficacy of Dialysis in Removing Metformin
- Research suggests that hemodialysis may have limited efficacy in removing metformin from the blood, with one study finding that only a small amount of metformin was removed during 6 hours of hemodialysis 7.
- However, another study found that a relatively large amount of metformin was eliminated in the urine during hemodialysis, suggesting that clinical improvement may be due to factors besides removal of metformin 7.
Clinical Outcomes
- Studies have reported successful treatment of lactic acidosis with dialysis, with patients experiencing significant improvement in their condition and eventual recovery 3, 4, 5, 6.
- Prolonged dialysis may be necessary in some cases to achieve optimal outcomes, particularly in patients with severe lactic acidosis or acute kidney injury 4, 6.