What is the treatment for lactic acidosis in Chronic Liver Disease (CLD)?

Treatment of Lactic Acidosis in Chronic Liver Disease

The treatment of lactic acidosis in chronic liver disease (CLD) requires organ support, identification and management of precipitating factors, and consideration for liver transplantation in appropriate candidates.

Pathophysiology and Causes in CLD

• Lactic acidosis in CLD occurs due to impaired lactate clearance by the damaged liver and increased lactate production from tissue hypoxia 1, 2
• Common precipitating factors include bacterial infections, GI bleeding, drug toxicity, and respiratory failure 3
• Cirrhosis can lead to hemodynamic dysfunction with hypoperfusion, contributing to anaerobic metabolism and lactate production 3

Initial Assessment and Management

• Patients with severe lactic acidosis in CLD should be treated in intermediate care or intensive care settings 3
• Identify and treat precipitating factors, particularly bacterial infections and GI bleeding 3
• Monitor organ function (liver, kidney, brain, lung, coagulation, circulation) frequently as acute-on-chronic liver failure (ACLF) is a dynamic condition 3

Hemodynamic Support

• Monitor hemodynamic function and administer vasopressor therapy for marked arterial hypotension 3
• Norepinephrine should be the first-line vasopressor if hypotension persists after fluid resuscitation 3
• Vasopressin can be added when hypotension persists despite norepinephrine use 3
• Use crystalloids as the initial fluid resuscitation of choice 3
• Avoid excessive volume expansion which can worsen organ function 3

Respiratory Support

• Provide oxygen therapy and ventilation if respiratory failure is present 3
• For patients with ACLF and ARDS, use low tidal volume strategy with appropriate PEEP levels 3
• Special care should be taken to preserve airway patency to prevent aspiration pneumonia 3

Renal Support

• If kidney failure is present, identify and manage its cause accordingly 3
• Consider continuous renal replacement therapy (CRRT) for patients with persistent hyperammonemia, hyperkalemia, and other metabolic abnormalities 3
• Early initiation of CRRT is recommended for patients with ACLF who have indications for urgent dialysis 3
• For hepatorenal syndrome, terlipressin with albumin or norepinephrine (if terlipressin unavailable) is recommended 3

Specific Treatments for Lactic Acidosis

• Avoid sodium bicarbonate administration for lactic acidosis as it has not been shown to improve survival and may have negative side effects 4, 5
• Discontinue any medications that may contribute to lactic acidosis (e.g., metformin) 6
• Hemodialysis may be considered for severe lactic acidosis, particularly in cases of drug-induced lactic acidosis 6, 5
• Ensure adequate oxygen delivery to tissues through appropriate hemodynamic and respiratory support 7

Liver Support Systems

• Extracorporeal liver support systems (albumin dialysis/MARS system, fractionated plasma separation/Prometheus system) have not shown significant effects on survival in ACLF 3
• Plasma exchange appears promising as a bridging therapy for patients with ACLF awaiting liver transplantation 3
• These systems should not be recommended routinely but may be considered in specific cases 3

Hepatic Encephalopathy Management

• Treat hepatic encephalopathy with lactulose (orally or rectally) or polyethylene glycol if patients are at risk of ileus/abdominal distention 3
• For patients with Grade 3 or 4 hepatic encephalopathy, consider ICU admission 3
• The use of osmotic laxatives (lactulose) to lower ammonia levels is not recommended in acute liver failure but remains standard therapy for hepatic encephalopathy in CLD 3

Consideration for Liver Transplantation

• Early referral to liver transplant centers for immediate evaluation is recommended for patients with ACLF 3
• Recurrent intractable hepatic encephalopathy, together with liver failure, is an indication for liver transplantation 3
• An early assessment for liver transplantation should be proposed for all patients with severe ACLF (ACLF-2 or ACLF-3) 3

Pitfalls and Caveats

• Avoid excessive volume expansion which can worsen organ function 3
• Do not delay transfer to a liver transplantation center when indicated 3
• Routine measurement of ammonia levels for diagnosis of hepatic encephalopathy is not recommended 3
• Withdrawal of intensive care support can be considered in patients who are not candidates for liver transplantation with four or more organ failures after one week of adequate intensive treatment 3