Is lactate beneficial for patients with End-Stage Renal Disease (ESRD)?

Lactate in ESRD Patients: Clinical Considerations and Management

Lactate should be used cautiously in ESRD patients due to potential accumulation and metabolic complications, with bicarbonate-based solutions preferred for dialysis and replacement fluids, especially in patients with hemodynamic instability or liver dysfunction.

Lactate Metabolism in ESRD

Lactate metabolism is significantly altered in patients with end-stage renal disease (ESRD) for several important reasons:

• ESRD patients have baseline abnormal lactate levels with a prevalence of approximately 17.7% even in stable outpatient settings 1
• The kidney plays a major role in lactate metabolism as a gluconeogenic organ involved in the glucose-lactate cycle 2
• Hemodialysis can reduce lactate levels by approximately 27% overall, with greater reductions (up to 62%) in patients with higher baseline lactate levels 1

Clinical Implications of Lactate in ESRD

Dialysis/Hemofiltration Solutions

When considering dialysis or hemofiltration solutions for ESRD patients:

• Bicarbonate is preferred over lactate as the buffer of choice for dialysis and replacement fluids, especially in patients with:

  • Hemodynamic instability/shock
  • Lactic acidosis
  • Liver failure 3

• Lactate-based solutions can cause:

  • Hyperlactatemia in all patients receiving hemofiltration
  • Worsening acid-base status in critically ill patients
  • Further depression of cardiac function 4

Energy Considerations

• Lactate provides 3.62 kcal/g when used as a buffer in dialysis/hemofiltration solutions 3
• Energy gain from lactate can be substantial (115-1300 kcal/day) depending on the type and rate of fluids used 3
• This caloric intake should be included in calculations of total daily energy provision to avoid overfeeding 3

Interpreting Lactate Levels in ESRD Patients

Lactate levels in ESRD patients require careful interpretation:

• Elevated lactate in ESRD patients presenting with acute illness does not necessarily indicate tissue hypoperfusion or gut ischemia 5
• In PD patients with intercurrent illness, elevated lactate was found in 29% of ED visits, often without signs of hemodynamic instability 5
• Transient disruption in metabolism of lactate absorbed from dialysis fluid may occur during acute illness 5

Recommendations for Clinical Practice

1. Buffer Selection:

   • Use bicarbonate-based solutions rather than lactate-based solutions for ESRD patients, especially those with:
     • Shock or hemodynamic instability
     • Liver dysfunction
     • Pre-existing lactic acidosis 3

2. Monitoring:

   • Monitor arterial pH when using lactate-based solutions, particularly in critically ill patients 4
   • Be prepared to substitute bicarbonate solutions if progressive acidosis develops 4

3. Nutritional Considerations:

   • Account for calories from lactate (3.62 kcal/g) when calculating total energy provision 3
   • Consider adjusting the macronutrient distribution to increase lipid intake and reduce carbohydrate provision based on altered substrate utilization in ESRD 3

4. Interpretation of Lactate Levels:

   • Interpret elevated lactate levels cautiously in ESRD patients presenting with acute illness
   • Recognize that elevated lactate may not always indicate tissue hypoperfusion or bowel ischemia in this population 5

Caveats and Pitfalls

• Avoid assuming that elevated lactate always indicates poor perfusion in ESRD patients
• Be cautious about ordering unnecessary abdominal imaging based solely on elevated lactate levels in ESRD patients 5
• Remember that exogenous lactate load from dialysis solutions may be well metabolized even in patients with acute renal failure and sepsis 2, but individual assessment is still necessary
• Consider that lactate accumulation in patients at their threshold for lactate utilization may worsen cardiac function and peripheral lactate metabolism 4

By carefully considering these factors, clinicians can make informed decisions about the use of lactate in ESRD patients to optimize outcomes related to morbidity, mortality, and quality of life.