Successful treatment of metformin-associated lactic acidosis without hemodialysis

Metformin-associated lactic acidosis (MALA) is a rare but potentially life-threatening condition. Hemodialysis is often recommended, but evidence of successful nondialytic management in children is limited. We report a girl with MALA successfully treated with supportive medical management without dialysis.

We report a girl with nondialyzed chronic kidney disease (CKD) and non-insulin-dependent diabetes mellitus (NIDDM), and dyslipidemia who developed MALA after 18 months of metformin, insulin, and sodium bicarbonate therapy. She presented with dyspnea, palpitations, and vomiting. She was lethargic, afebrile, tachypneic, tachycardic, hypertensive, and had Kussmaul breathing. Laboratory results showed blood glucose 55 mg/dL, potassium 6.7 mEq/L, arterial pH 7.038, pCO₂ <5 mmHg, and lactate 19.55 (0.56-1.39) mmol/L. She was diagnosed with CKD and NIDDM complicated by acute kidney injury and MALA. She was treated with intravenous glucose, sodium bicarbonate, respiratory support, and rectal calcium polystyrene sulfonate and then referred to our hospital, arriving 9 h after the initial presentation. For MALA, hemodialysis (HD) or continuous renal replacement therapy (CRRT) was considered, but predialysis COVID-19 testing requirements delayed immediate initiation. Intravenous fluids were maintained at 100-150 cc/h with urine output of 200-220 cc/h. Seven hours after arrival, laboratory results improved (pH 7.361, lactate 11.7 mmol/L), so HD/CRRT was deferred. Serum bicarbonate and lactate normalized at 25 and 29 h, respectively.

This report supports that pediatric MALA can be successfully treated without renal replacement therapy, using liberal hydration, alkali therapy, and measures to ensure adequate urine output.