How to manage lactic acidosis in chronic liver disease (CLD)?

Management of Lactic Acidosis in Chronic Liver Disease

Metformin should not be used in patients with decompensated cirrhosis, especially when there is concomitant renal impairment, because of the high risk of lactic acidosis. 1

Pathophysiology and Risk Factors

• Lactic acidosis in chronic liver disease (CLD) results from both increased lactate production and decreased clearance, as the liver is a major site for lactate metabolism 2, 3
• The risk of lactic acidosis is significantly higher in patients with:
  • Decompensated cirrhosis 1
  • Concurrent renal impairment 1
  • Hypoperfusion states (shock, hypotension) 3
  • Tissue hypoxia 3

Management Algorithm

1. Identify and Address Precipitating Factors

• Early identification and treatment of precipitating factors is crucial 1
• Common precipitating factors include:
  • Bacterial infections (particularly spontaneous bacterial peritonitis) 1
  • Gastrointestinal bleeding 1
  • Drug toxicity (especially metformin) 1
  • Hypoperfusion states 3

2. Medication Management

• Discontinue metformin immediately in patients with:

  • Decompensated cirrhosis 1
  • GFR < 30 mL/min/1.73m² 1
  • Acute kidney injury 1
  • Serious intercurrent illness 1

• For diabetes management in CLD patients with lactic acidosis:

  • Use insulin as the preferred agent for glycemic control 1
  • Consider GLP-1 receptor agonists in Child-Pugh class A cirrhosis only 1
  • SGLT2 inhibitors can be used in Child-Pugh class A and B cirrhosis 1
  • Avoid sulfonylureas in hepatic decompensation due to risk of hypoglycemia 1

3. Supportive Care and Organ Support

• Provide hemodynamic support:

  • Use crystalloids as initial fluid resuscitation 1
  • If hypotension persists, norepinephrine should be first-line vasopressor 1
  • Vasopressin can be added for persistent hypotension 1

• Monitor and support respiratory function:

  • Provide oxygen therapy and ventilation if respiratory failure develops 1
  • For patients with ARDS, use low tidal volume strategy 1

• Renal support:

  • Early initiation of continuous renal replacement therapy (CRRT) for persistent hyperammonemia, hyperkalemia, and metabolic abnormalities 1
  • Terlipressin with albumin for hepatorenal syndrome 1

4. Nutritional Support

• Provide adequate nutritional support:
  • 35 kcal/kg of body weight/day 1
  • Protein intake of 1.2-1.5 g/kg of body weight/day 1
  • Include late evening snack for patients with sarcopenia or decompensated cirrhosis 1

5. Specific Treatments for Lactic Acidosis

• Avoid sodium bicarbonate as it may increase lactate production 3, 4
• Consider CRRT for severe, refractory lactic acidosis, though evidence for efficacy is limited 3
• The ideal treatment is addressing the underlying disorder 3

Special Considerations

• Patients with acute-on-chronic liver failure (ACLF) and lactic acidosis should be treated in intermediate or intensive care settings 1
• Early referral to liver transplant centers for immediate evaluation is recommended for eligible patients 1
• Extracorporeal liver support systems (MARS, Prometheus) have not shown significant survival benefits and are not recommended outside clinical trials 1

Monitoring

• Frequent monitoring of organ function (liver, kidney, brain, lung, coagulation, circulation) is essential as ACLF is a dynamic condition 1
• Monitor lactate levels, arterial blood gases, and electrolytes regularly 5
• Assess for clinical improvement or deterioration to guide ongoing management 1