From the Guidelines
Thiamine (Vitamin B1) plays a crucial role in the recovery of lactic acidosis-related liver failure by serving as an essential cofactor for several key enzymes involved in cellular energy metabolism. When administered to patients with lactic acidosis and liver dysfunction, thiamine typically requires doses of 100-300 mg intravenously for 3-4 days, as recommended by the latest ESPEN micronutrient guideline 1.
Key Points to Consider
- Thiamine deficiency impairs the function of pyruvate dehydrogenase complex, which normally converts pyruvate to acetyl-CoA for entry into the Krebs cycle, and without adequate thiamine, pyruvate accumulates and is instead converted to lactate, worsening acidosis 1.
- Thiamine supplementation rapidly restores these enzymatic pathways, allowing for improved pyruvate metabolism, decreased lactate production, and enhanced hepatic lactate clearance 1.
- This intervention is particularly important in patients with chronic alcoholism, malnutrition, or prolonged parenteral nutrition, as these conditions commonly lead to thiamine deficiency that can precipitate or worsen lactic acidosis and liver dysfunction 1.
Clinical Recommendations
- Administer thiamine (100-300 mg/day IV) to patients admitted to emergency or intensive care without hesitation for 3-4 days, as recommended by the ESPEN micronutrient guideline 1.
- Consider oral supplementation of 100 mg daily until recovery, as thiamine deficiency can lead to severe clinical consequences, including congestive cardiac failure and lactic acidosis 1.
Important Considerations
- Thiamine is rapidly absorbed in the jejunum and ileum by an active, carrier-mediated, and rate-limited process, but at higher concentrations, the uptake is by passive diffusion 1.
- The plasma levels of amino acids are raised 3- to 4-fold in acute liver failure, and the amino acid pattern is characterized by a decrease in branched chain amino acids and an increase in tryptophan, aromatic and sulfur-containing amino acids 1.
From the Research
Role of Thiamine in Recovery of Lactic Acidosis-Related Liver Failure
- Thiamine plays a critical role in energy metabolism, and its deficiency can lead to severe lactic acidosis 2.
- Thiamine deficiency can cause lactic acidosis, which may be refractory to conventional treatments, but responsive to thiamine replenishment 3, 4, 5.
- In cases of lactic acidosis-related liver failure, thiamine supplementation can help resolve the condition by restoring lactate metabolism 3, 6, 5.
- The use of hemodiafiltration (HDF) in combination with thiamine administration can be an effective treatment for severe lactic acidosis due to thiamine deficiency 6.
- Thiamine deficiency should be considered in every case of severe lactic acidosis without an obvious cause, especially in high-risk populations, and empiric treatment with thiamine should be initiated immediately 4.
- Thiamine replacement therapy can rapidly normalize serum lactate levels and acid-base status, and improve clinical condition in patients with thiamine deficiency-related lactic acidosis 3, 5.