Mini-Tweetorial on Metformin Associated Lactic Acidosis (MALA)

How small can you make a tweetorial? This one is only 5 tweets.

You see this patient. Good medical management helps with the potassium but after resuscitation, creatinine not much improved. Acidosis is worse despite a few doses of bicarb. pic.twitter.com/51IjqN70Qq

— Joel M. Topf, MD FACP (@kidney_boy) March 9, 2020

A lot of patients are on metformin and a lot of people get lactic acidosis. One does not always cause the other.

But in this case I think the metformin did cause the lactic acidosis. The patient did not have sepsis. There wasn’t any dead bowel, shock, or other typical cause of lactic acidosis. And thanks for asking, the thiamine was normal, they were not being poisoned with arsenic. No aspirin toxicity. No malignancy causing an occult type B lactic acidosis.

They had acute tubular necrosis causing acute kidney injury.

The lactate was sky high

Perfusion was intact. Blood pressures were in the 160s.

And they were taking a coupe grams of metformin a day. The thing about a creatinine of 8 is you need to have a GFR of around zero for almost week to get there. So imagine the patient has about 14 grams of metformin on board.

I think this was MALA.

I think this patient should have gotten hemodialysis.