From the Guidelines
Dialysis is not recommended as a primary treatment for lactic acidosis, except in severe cases where it is refractory to conventional treatments or life-threatening, and the underlying cause is addressed. When considering the management of lactic acidosis, it's crucial to prioritize treating the underlying cause, such as sepsis or shock, and using medical management with intravenous fluids and vasopressors as needed 1. The use of sodium bicarbonate is also suggested against in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15, due to the lack of evidence supporting its effectiveness in improving hemodynamics or reducing vasopressor requirements 1. In terms of dialysis, while it can remove lactate and hydrogen ions from the bloodstream, helping to correct the acid-base imbalance, its use should be considered on a case-by-case basis, taking into account the severity of acidosis and the patient's clinical condition 1. Some key points to consider when deciding on dialysis for lactic acidosis include:
- The severity of acidosis, typically pH < 7.2 or bicarbonate < 12 mEq/L
- The patient's clinical condition and whether the underlying cause is reversible
- The potential benefits and risks of dialysis, including the removal of lactate and hydrogen ions, and the potential for complications such as fluid overload or electrolyte imbalances
- The preference for continuous renal replacement therapy (CRRT) over intermittent hemodialysis in hemodynamically unstable patients 1. It's essential to weigh these factors and consider the most recent and highest quality evidence when making a decision about dialysis for lactic acidosis, prioritizing the patient's morbidity, mortality, and quality of life as the primary outcomes.
From the Research
Usefulness of Dialysis in Lactic Acidosis
- Dialysis can be useful in treating lactic acidosis, particularly in cases where the underlying cause is metformin-associated lactic acidosis (MALA) 2, 3.
- Hemodialysis has been shown to be effective in improving outcomes in patients with MALA, especially when initiated early and performed for a prolonged period 2, 3.
- Peritoneal dialysis is also an option for treating MALA, particularly in patients with end-stage renal disease 4.
- Dialysis can help remove excess lactate and correct acid-base imbalances, which can improve cardiovascular function and reduce mortality 5.
- The choice of dialysis modality and duration of treatment may depend on the individual patient's condition and the underlying cause of lactic acidosis 2, 3, 4.
Key Considerations
- Metformin-associated lactic acidosis is a rare but potentially life-threatening condition that requires prompt recognition and treatment 2, 3.
- Identifying metformin levels can help in diagnosis and management, but this may not be widely available 2.
- Patients receiving metformin should be counseled to stop metformin and seek medical care in the setting of illnesses, particularly those that may increase the risk of kidney dysfunction 2.
- Dialysis should be considered as an early treatment option in cases of severe lactic acidosis, particularly when routine measures are ineffective 6, 3.