From the Research
Lactic acidosis in Nephrotic Syndrome (NS) is primarily caused by metformin accumulation due to renal impairment, rather than the nephrotic syndrome itself. The most recent and highest quality study, 1, suggests that metformin-associated lactic acidosis (MALA) occurs when metformin use is continued in the presence of renal impairment, leading to reduced lactate clearance and increased risk of lactic acidosis.
Key Factors Contributing to Lactic Acidosis
- Metformin use in patients with renal impairment
- Reduced renal elimination of metformin
- Excessive alcohol consumption
- Presence of other concurrent causes of lactic acidosis, such as sepsis
Diagnosis and Management
- Suspect MALA in patients with high anion gap metabolic acidosis and lactate levels exceeding 5 mmol/L
- Confirm diagnosis with laboratory tests and clinical evaluation
- Treatment involves immediate cessation of metformin, supportive management, and addressing concurrent causes of lactic acidosis
- Severe MALA may require extracorporeal removal of metformin using intermittent hemodialysis or continuous kidney replacement therapy, as recommended by 2 and 1
Prevention and Monitoring
- Monitor lactate levels and acid-base status in patients at risk for lactic acidosis
- Consider alternative treatments for diabetes in patients with renal impairment
- Ensure patients are aware of the risks of lactic acidosis and the importance of discontinuing metformin in the event of renal impairment or other predisposing factors, as emphasized by 2 and 1