scholarly journals Early Initiation of Hemodialysis for Progressive Lactic Acidosis in a Diabetic Patient

2018 ◽  
Vol 1 (1-3) ◽  
pp. 17-20
Author(s):  
Keisuke Nyunoya ◽  
Naoki Hayase ◽  
Kent Doi ◽  
Toshifumi Asada ◽  
Yoshihiro Ueda ◽  
...  
Keyword(s):  
Intensive Care ◽  
Lactic Acidosis ◽  
Altered Mental Status ◽  
Early Initiation ◽  
Critical Conditions ◽  
Diabetic Patients ◽  
Severe Lactic Acidosis ◽  
Metformin Concentration ◽  
History Of ◽  
Lactate Levels

Metformin, a widely used medicine for diabetes mellitus, is well known to cause lactic acidosis, which may require intensive care, including hemodialysis, especially in severe cases because of the high mortality rate. Because metformin is effectively removed by renal replacement therapy, early initiation of hemodialysis is crucial for metformin overdose. We report a case of a 38-year-old male who was brought to our emergency department (ED) with altered mental status. He subsequently developed severe lactic acidosis with a peak lactate level of 33.4 mmol/L. No clear etiology was identified for these critical conditions at the ED. Although metformin intoxication could not be confirmed at this time, we decided to start hemodialysis immediately. Soon after hemodialysis, blood pH and lactate levels dramatically improved. The patient fully recovered after 9 days of intensive care unit (ICU) stay. Later on, his serum metformin concentration was revealed to be 146 μg/mL and 26 μg/mL at ICU admission and after dialysis at day 3, respectively (therapeutic range, 1–2 μg/mL). Early initiation of hemodialysis might be beneficial for diabetic patients with unexplained severe lactic acidosis despite uncertainties in history of overdose or serum concentration of metformin.

Lactic acidosis had developed in diabetic patients receiving herbal therapy

MedPharmRes ◽  
2021 ◽  
Vol 5 (2) ◽  
pp. 22-28
Author(s):  
Uyen Vy Doan ◽  
Thanh Thao T. Nguyen ◽  
Thuy An Nguyen ◽  
Van Hoang Lam ◽  
Duong Tien Truong ◽  
...  
Keyword(s):  
Blood Glucose ◽  
Lactic Acidosis ◽  
Glucose Control ◽  
Blood Glucose Control ◽  
Clinical Findings ◽  
Series Data ◽  
Diabetic Patients ◽  
Herbal Products ◽  
Severe Lactic Acidosis ◽  
Two Samples

Introduction: Herbal antidiabetic products are popular in Vietnam. Many cases have presented to hospitals with severe lactic acidosis, shock and were ultimately fatal. We reviewed the clinical findings of these patients for factors that contributed to their illness and death, and analyzed the ingredients contained in these herbal products sold for diabetic treatment. Method: This was a single-center, retrospective, observational case series. Data were collected on all cases who presented with severe lactic acidosis after use of traditional herbal anti-diabetic pills, over the two-year time period 2018 – 2019. Past medical histories and clinical findings were reviewed. Samples of the herbal anti-diabetic products, and patient blood and urine were analyzed. Results: A total of 18 cases of severe lactic acidosis associated with use of herbal anti-diabetic pills were reviewed. These patients had a diagnosis of diabetes for an average of 9 years (9.4 ± 4.6 years). The use of these herbals for blood glucose control ranged from one month to 8 years; approximately 50% of these patients consumed these products over a year’s time. Only two cases had combined herbal products and metformin 500 mg. A total mean of herbal pills consumed was 9 (SD ± 8); patients commonly took combinations of 2 different colored tablets. Major manifestations included gastrointestinal disorders, severe metabolic acidosis (pH = 6.85 ± 0.22, HCO3- = 4.4 ± 2.6), with multi-organ failure and shock on admission. Hyperlactatemia was present in all cases (195 ± 74 mg/dL). For lactate removal and acidosis correction, intermittent hemodialysis or continuous renal replacement therapy was performed, ranging from 2 hours to 72 hours depending on the severity of lactic acidosis and patient need. The mortality rate was 33.3% and all these patients became hypoglycemic, either at initial presentation or during treatment. 22 samples of herbal pills were available for testing that contained the biguanides metformin and phenformin, with a higher concentration of phenformin than metformin if both were present, Phenformin was presented in all samples. Arsenic was found in two samples. Conclusion: Biguanides are an effective treatment for diabetes and were added to traditional herbal pills sold and used for blood glucose control. Many users of these products are doing so because of the cost and perception of the safety of natural remedies. Biguanide poisoning may still occur even in patients without renal impairment.

Patients with Severe Lactic Acidosis in the Intensive Care Unit: A Retrospective Study of Contributing Factors and Impact of Renal Replacement Therapy

2021 ◽  
pp. 1-7
Author(s):  
Lyssa Van De Ginste ◽  
Floris Vanommeslaeghe ◽  
Eric A.J. Hoste ◽  
Jan M. Kruse ◽  
Wim Van Biesen ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Lactic Acidosis ◽  
Replacement Therapy ◽  
Lactate Level ◽  
Cohort Analysis ◽  
Adverse Outcomes ◽  
Contributing Factors ◽  
Severe Lactic Acidosis

<b><i>Introduction:</i></b> Hyperlactatemia is a regular condition in the intensive care unit, which is often associated with adverse outcomes. Control of the triggering condition is the most effective treatment of hyperlactatemia, but since this is mostly not readily possible, extracorporeal renal replacement therapy (RRT) is often tried as a last resort. The present study aims to evaluate the factors that may contribute to the decision whether to start RRT or not and the potential impact of the start of RRT on the outcome in patients with severe lactic acidosis (SLA) (lactate ≥5 mmol/L). <b><i>Materials and Methods:</i></b> We conducted a retrospective single-center cohort analysis over a 3-year period including all patients with a lactate level ≥5 mmol/L. Patients were considered as treated with RRT because of SLA if RRT was started within 24 h after reaching a lactate level ≥5 mmol/L. <b><i>Results:</i></b> Overall, 90-day mortality in patients with SLA was 34.5%. Of the 1,203 patients who matched inclusion/exclusion criteria, 11% (<i>n</i> = 133) were dialyzed within 24 h. The propensity to receive RRT was related to the lactate level and to the SOFA renal and cardio score. The most frequently used modality was continuous RRT. Patients who were started on RRT versus those who did not have 2.3 higher odds of mortality, even after adjustment for the propensity to start RRT. <b><i>Conclusions:</i></b> Our analysis confirms the high mortality rate of patients with SLA. It adds that odds for mortality is even higher in patients who were started on RRT versus not. We suggest keeping an open mind to the factors that may influence the decision to start dialysis and bear in mind that without being a bridge to correction of the underlying condition, dialysis is unlikely to affect the outcome.

scholarly journals Hyperlactatemia and the Outcome of Type 2 Diabetic Patients Suffering Acute Myocardial Infarction

2016 ◽  
Vol 2016 ◽  
pp. 1-7 ◽  
Author(s):  
Jovanovic Aleksandar ◽  
Peric Vladan ◽  
Snezana Markovic-Jovanovic ◽  
Radojica Stolic ◽  
Jadranka Mitic ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Myocardial Infarction ◽  
Lactic Acidosis ◽  
Blood Lactate ◽  
Lactate Production ◽  
Diabetic Patients ◽  
Lethal Outcome ◽  
Lactate Levels

Background.Increased lactate production is frequent in unregulated/complicated diabetes mellitus.Methods.Three groups, each consisting of 40 patients (type 2 diabetics with myocardial infarction, DM+AMI, nondiabetics suffering myocardial infarction, MI, and diabetics with no apparent cardiovascular pathology, DM group), were tested for pH, serum bicarbonate and electrolytes, blood lactate, and CK-MB.Results. Blood lactate levels were markedly higher in AMI+DM compared to MI group (4.54±1.44versus3.19±1.005 mmol/L,p<0.05); they correlated with the incidence of heart failure(ρ=0.66), cardiac rhythm disorders(ρ=0.54), oxygen saturation(ρ=0.72), CK-MB levels(ρ=0.62), and poor short-term outcome. Lactic acidosis in DM+AMI group was not always related to lethal outcome.Discussion. The lactate cutoff value associated with grave prognosis depends on the specific disease. While some authors proposed cutoff values ranging from 0.76 to 4 mmol/L, others argued that only occurrence of lactic acidosis may be truly predictive of lethal outcome.Conclusion. Both defective glucose metabolism and low tissue oxygenation may contribute to the lactate production in diabetic patients with acute myocardial infarction; high lactate levels indicate increased risk for poor outcome in this population comparing to nondiabetic patients. The rise in blood lactate concentration in diabetics with AMI was associated with increased incidence of heart failure, severe arrhythmias, cardiogenic shock, and high mortality rate.

scholarly journals Severe lactic acidosis from acute cyanide poisoning after intentional amygdalin ingestion in a teenager

2020 ◽  
Vol 16 (3) ◽  
Author(s):  
Jack Green
Keyword(s):  
Lactic Acidosis ◽  
Signs And Symptoms ◽  
Altered Mental Status ◽  
The United States ◽  
Oral Route ◽  
Rare Entity ◽  
Cyanide Poisoning ◽  
Bedside Clinician ◽  
History Of ◽  
History Of Depression

Cyanide poisoning via the oral route is a remarkably rare entity in the United States. Though acute toxicity from this poison may present with classic signs and symptoms (smell of bitter almonds on breath and cherry-red skin), these signs are frequently not clinically observed in the intoxicated patient, making it low on the routine differential diagnosis leading to both diagnostic and therapeutic challenges for the bedside clinician. This is a case of a 17-yearold male with a history of depression who presented to the Emergency Room (ER) with altered mental status, abdominal pain, and emesis. A severely elevated and worrisome lactic acidosis triggered the ER’s septic shock bundle and algorithm, but further investigation ultimately led to the unifying diagnosis of intentional cyanide poisoning.

scholarly journals Acidosis láctica asociada a metformina

2019 ◽  
Vol 11 (5) ◽  
pp. 2
Author(s):  
Maria Fernández Rodríguez ◽  
J Álvarez del Vayo ◽  
A Pascual Casado ◽  
E Zaldibar Enríquez
Keyword(s):  
Lactic Acidosis ◽  
Type Ii Diabetes ◽  
Intestinal Ischemia ◽  
Exploratory Laparotomy ◽  
Diabetic Patients ◽  
Severe Lactic Acidosis ◽  
Drug Of Choice ◽  
Normal Limits ◽  
Oral Antidiabetic ◽  
Elimination Half

La acidosis láctica severa asociada a metformina es una enfermedad grave, poco frecuente, pero con elevada mortalidad que se define en presencia de un pH < 7,35, Lactato > 2 mmol/L y una paCO2  en límites normales.  Presentamos el caso de una paciente en tratamiento con metformina, hipertensa y dislipémica, polimedicada, con acidosis láctica grave ingresada en Reanimación, tras postoperatorio de laparotomía exploradora por sospecha de una isquemia intestinal.  Llega en estado de shock circulatorio, con escasa respuesta a administración de volumen y drogas vasoactivas. Describimos algunos datos sobre su incidencia, la fisiopatología, el pronóstico y el tratamiento, así como la importancia de un diagnóstico precoz y diferencial con otras causas de acidosis metabólicas que eleven el anion GAP.  ABSTRACT Lactic acidosis associated with metformin Metformin is an oral antidiabetic that belongs to the group of the biguainides. It is the drug of choice for the treatment of type II diabetes due to its efficacy and safety. It is a small molecule, whose elimination half-life is 8 to 20 hours in people with normal renal function. Severe lactic acidosis associated with metformin is a serious, infrequent disease (its incidence is estimated between 3-8 cases per 100,000 diabetic patients and year) but with high mortality (around 40% in accidental poisonings), which is defined in presence of a pH <7.35, lactate> 2 mmol / L and a paCO2 in normal limits. We present the case of a diabetic patient under treatment with metformin, hypertense and dyslipidemic, polymedicated, with severe lactic acidosis, in a Reanimation Care unit, after postoperative exploratory laparotomy due to suspicion of intestinal ischemia. He arrives in a state of circulatory shock, with little response to the administration of volume and vasoactive drugs. We describe some data about its incidence, pathophysiology, prognosis and treatment, as well as the importance of an early and differential diagnosis with other causes of metabolic acidosis that elevate the GAP anion.

scholarly journals New onset COVID-19–related diabetes: an indicator of mortality

2020 ◽  
Author(s):  
Jin-Kui Yang ◽  
Jian-Min Jin ◽  
Shi Liu ◽  
Peng Bai ◽  
Wei He ◽  
...  
Keyword(s):  
Intensive Care ◽  
High Mortality ◽  
Organ Injury ◽  
Critical Conditions ◽  
Clinical Practices ◽  
Glucose Testing ◽  
Onset Diabetes ◽  
History Of ◽  
Poor Outcomes ◽  
New Onset

SummaryBackgroundConcomitance with diabetes is associated with high mortality in critical conditions. Patients with previous diabetes are more vulnerable to COVID-19. However, new-onset COVID-19–related diabetes (CRD) and its relevance have scarcely been reported. This study investigates new-onset CRD and its correlation with poor outcomes or death in patients with COVID-19.MethodsWe performed a single center, retrospective case series study in 120 patients with laboratory confirmed COVID-19 at a university hospital. Fasting blood glucose (FBG) ≥7.0 mmol/L for two times during hospitalization and without a history of diabetes were defined as CRD. The Critical status was defined as admitted to intensive care unit (ICU) or death.ResultsAfter excluding patients with a history of diabetes, chronic heart, kidney, and liver disease, 69 patients with COVID-19 were included in the final analysis. Of the 69 patients, 23 were Moderate, 20 were Severe, and 26 were Critical (including 16 deceased patients). The prevalence of CRD in Critical and Moderate+Severe patients was 53.85% and 13.95%, respectively. Kaplan-Meier survival analysis revealed a significantly higher mortality rate in patients with CRD (P=0.0019). Multivariable analysis indicated that CRD was an independent predictor for death (HR = 3.75, 95% CI 1.26-11.15). Cluster analysis suggested that indicators for multi-organ injury were interdependent, and more proximities of FBG with indicators for multi-organ injury was present.ConclusionOur results suggest that new onset COVID-19–related diabetes is an indicator of multi-organ injury and predictor for poor outcomes and death in COVID- 19 patients. As it is easy to perform for clinical practices and even self-monitoring, glucose testing will be much helpful for predicting poor outcomes to facilitate appropriate intensive care in patients with COVID-19.FundingNational Key Research and Development Program of China; The Beijing Science and Technology Project.Significance of this studyEvidence before this studyConcomitance with diabetes is associated with high mortality in critical conditions. Patients with previous diabetes are more vulnerable to COVID-19. However, new-onset COVID-19–related diabetes (CRD) and its relevance have scarcely been reported. Recently, an international group of leading diabetes researchers participating in the CoviDIAB Project have established a global registry of patients with Covid-19–related diabetes (covidiab.e-dendrite.com).Added value of this study?New-onset diabetes in COVID-19 defined as CRD was investigated. Correlation between CRD and poor outcomes or death in patients with COVID-19 was found. About half of the Critical patients have new onset CRD. CRD is the representative of the clustered indicators of multi-organ injury and is the predictor for poor outcomes and death.How might these results change the focus of research or clinical practice?Our results suggest that new onset diabetes is an indicator of multi-organ injury and predictor for poor outcomes and death in COVID-19 patients. The study of CRD may also uncover novel mechanisms of disease.

Phenformin-Induced Lactic Acidosis: A Forgotten Adverse Drug Reaction

1993 ◽  
Vol 27 (10) ◽  
pp. 1183-1187 ◽  
Author(s):  
Margaret E. McGuinness ◽  
Robert L. Talbert
Keyword(s):  
Diabetes Mellitus ◽  
Lactic Acidosis ◽  
Lactate Concentration ◽  
Blood Gases ◽  
Diabetic Patients ◽  
Arterial Blood ◽  
The Us ◽  
History Of ◽  
Treatment Of Diabetes ◽  
Upper Abdominal

OBJECTIVE: To document a case of severe metabolic and lactic acidosis secondary to phenformin. This adverse effect has almost been forgotten as 15 years have passed since its withdrawal from the US market. CASE SUMMARY: A 64-year-old man presented with a four-day history of left upper abdominal pain and a one-week history of constipation and diarrhea. His arterial blood gases were pH 6.7, pCO2 2.80 kPa, and pO2 12.00 kPa with 90% oxygen saturation on room air. Serum chemistries indicated an unmeasurable serum bicarbonate concentration, anion gap 52 mmol/L, lactate concentration 29.5 mmol/L, blood urea nitrogen 6.63 mmol/L, creatinine 229.84 μmol/L, and blood glucose 4.35 mmol/L. There were low levels of urine and serum ketones. In the emergency department, he required resuscitation for hypotension and bradycardia. His diagnosis was lactic and ketoacidosis secondary to phenformin. The patient was treated with NaCl 0.9%, sodium bicarbonate, insulin, and hemodialysis. Although he survived the initial insult of lactic and ketoacidosis, his hospital course was complicated and he died on hospital day 105. CONCLUSIONS: Treatment of lactic acidosis is difficult and challenging. The continued availability of phenformin in neighboring countries, and the renewed interest in biguanide therapy for treating diabetes mellitus make it an important diagnosis of exclusion in diabetic patients who present with severe acidosis. Metformin, another biguanide under investigation for the treatment of diabetes mellitus, is associated with a much lower incidence of lactic acidosis than is phenformin.

scholarly journals Metformin-Induced Lactic Acidosis: A Question of Time

2020 ◽  
Vol 2020 ◽  
pp. 1-4
Author(s):  
Céline Bellefroid ◽  
Pierre Goffin ◽  
Julien Guntz ◽  
Marine Deville
Keyword(s):  
Lactic Acidosis ◽  
Type Ii Diabetes ◽  
High Flow ◽  
Type Ii ◽  
Severe Lactic Acidosis ◽  
Oral Antidiabetic ◽  
Metformin Concentration ◽  
Life Threatening

Metformin is an oral antidiabetic largely prescribed in the treatment of type II diabetes. Overdose is associated with life-threatening lactic acidosis. We report the case of the highest metformin concentration ever described secondary to a voluntary suicidal intake. The patient developed a severe lactic acidosis and hemodynamic shock successfully treated with high-flow hemofiltration. Time to start extrarenal epuration is capital to avoid poor evolution.

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