How to manage lactate levels in ESRD?

Management of Lactate Levels in ESRD

Bicarbonate-buffered solutions should be used instead of lactate-buffered solutions for dialysis in ESRD patients with elevated lactate levels or risk factors for lactic acidosis. 1

Pathophysiology of Lactate in ESRD

Patients with end-stage renal disease (ESRD) have impaired ability to excrete acid produced by normal metabolic processes, which can contribute to acid-base disturbances. Additionally, ESRD patients may have:

• Baseline abnormal lactate levels (prevalence of 17.7% in outpatient ESRD population) 2
• Reduced ability to metabolize exogenous lactate from dialysis solutions
• Risk of developing lactic acidosis, particularly when using lactate-buffered solutions in certain clinical scenarios

Assessment of Lactate Levels

• Monitor serum lactate levels regularly in ESRD patients
• Pay particular attention to lactate levels in patients with:
  • Liver dysfunction
  • Cardiovascular instability
  • Sepsis or other hypoperfusion states
  • Medications that may increase lactate (e.g., metformin)

Management Algorithm for Lactate in ESRD

1. Choice of Buffer in Dialysis Solutions

• First-line choice: Bicarbonate-buffered solutions for all ESRD patients 1
• Avoid lactate-buffered solutions in patients with:
  • Elevated baseline lactate levels
  • Liver dysfunction
  • Hemodynamic instability
  • Lactic acidosis
  • Sepsis or shock states

2. Monitoring During Dialysis

• Monitor acid-base status during dialysis, particularly when using lactate-buffered solutions
• Watch for signs of worsening acidosis:
  • Decreasing serum bicarbonate
  • Increasing anion gap
  • Hemodynamic instability

3. Management of Elevated Lactate

• For mild elevation:

  • Switch from lactate-buffered to bicarbonate-buffered dialysis solutions
  • Optimize hemodynamics to improve tissue perfusion
  • Consider increasing dialysis dose to enhance lactate clearance

• For severe elevation or lactic acidosis:

  • Immediate hemodialysis with bicarbonate buffer
  • Correct underlying causes (hypoperfusion, medication effects)
  • Consider bicarbonate supplementation if severe acidosis is present

4. Special Considerations

• Metformin users: Discontinue metformin in ESRD patients (contraindicated with eGFR <30 mL/min/1.73m²) 3
• Hemodynamically unstable patients: Avoid lactate-buffered solutions as they can worsen hypotension 4
• Patients with liver dysfunction: Use bicarbonate-buffered solutions exclusively as these patients have impaired lactate metabolism 5

Evidence Quality and Considerations

The recommendation to use bicarbonate-buffered solutions is supported by moderate-quality evidence. A study by Davenport et al. demonstrated that patients with hepatorenal failure developed worsening acidosis when given lactate-buffered solutions, with a correlation between maximum blood lactate and increase in arterial hydrogen ion concentration (r = 0.76, P < 0.001) 5.

Hemodialysis itself can significantly reduce elevated lactate levels, with one study showing an overall decrease of 27% after dialysis, and even greater reductions (62%) in patients with higher baseline lactate levels (2.5-3.9 mmol/L) 2.

Common Pitfalls to Avoid

1. Using lactate-buffered solutions in all patients: This can worsen acidosis in vulnerable patients
2. Ignoring baseline lactate levels: Pre-dialysis assessment of lactate is important for proper buffer selection
3. Overlooking medication effects: Certain medications like metformin can contribute to lactic acidosis and should be discontinued in ESRD patients
4. Failing to monitor acid-base status during dialysis: Regular monitoring is essential, especially in high-risk patients

By following this approach, clinicians can effectively manage lactate levels in ESRD patients and minimize the risk of complications related to acid-base disturbances.