Sustained low-efficiency dialysis for metformin-associated lactic acidosis in patients with acute kidney injury

• Published in: Journal of nephrology 2019-04, Vol.32 (2), p.297-306
• Main Authors: Greco, Paolo, Regolisti, Giuseppe, Maggiore, Umberto, Ferioli, Elena, Fani, Filippo, Locatelli, Carlo, Parenti, Elisabetta, Maccari, Caterina, Gandolfini, Ilaria, Fiaccadori, Enrico
• Format: Article
• Language: English
• Subjects: Acidosis, Lactic - chemically induced; Acidosis, Lactic - diagnosis; Acidosis, Lactic - mortality; Acidosis, Lactic - therapy; Acute Kidney Injury - chemically induced; Acute Kidney Injury - diagnosis; Acute Kidney Injury - mortality; Acute Kidney Injury - therapy; Aged; Aged, 80 and over; Diabetes Mellitus, Type 2 - diagnosis; Diabetes Mellitus, Type 2 - drug therapy; Female; Humans; Hybrid Renal Replacement Therapy - adverse effects; Hybrid Renal Replacement Therapy - mortality; Hypoglycemic Agents - adverse effects; Hypoglycemic Agents - blood; Hypoglycemic Agents - pharmacokinetics; Male; Medicine; Medicine & Public Health; Metformin - adverse effects; Metformin - blood; Metformin - pharmacokinetics; Middle Aged; Models, Biological; Nephrology; Original Article; Risk Factors; Toxicokinetics; Treatment Outcome; Urology
• ISSN: 1121-8428; 1724-6059
• DOI: 10.1007/s40620-018-00562-2

Background The choice of the specific modality and treatment duration of renal replacement therapy (RRT) to adopt in metformin-associated lactic acidosis (MALA) is still debated. We aimed to verify if sustained low-efficiency dialysis (SLED) is a rational choice in patients with MALA and acute kidney injury (AKI). Methods We collected serial serum metformin measurements, clinical parameters, and outcome data in ten consecutive patients (mean age 77 years [range 58–88], 5 males) admitted to our renal intensive care unit for suspected MALA associated with AKI and hemodynamic instability. Patients underwent a 16-h SLED session performed with either conventional dialysis machines or machines for continuous RRT (CRRT). A 2-compartment open-infusion pharmacokinetic model with first-order elimination was fitted to each subject’s serum concentration–time data to model post-SLED rebound and predict the need for further treatments. Results Two patients died within 24 h after SLED start. Three patients needed one further dialysis session. Surviving patients (n = 8) were dialysis-free at discharge. Metformin levels were in the toxic range at baseline (median [range] 32.5 mg/l [13.6–75.6]) and decreased rapidly by the end of SLED (8.1 mg/l [4.5–15.8], p