背景:二甲双胍由于其成本效益和有利的不良反应而被广泛认为是一线抗血糖药。然而,在估计肾小球滤过率<30mL/min/1.73m2的患者中禁止使用,由于潜在致命性二甲双胍相关性乳酸性酸中毒(MALA)的风险。我们试图评估我们机构的MALA病例和结果。
方法:在这个观察中,回顾性病例系列,我们回顾了2013年1月至2022年5月期间所有二甲双胍水平患者的EMR,以确定符合MALA诊断标准的患者.我们评估了MALA的危险因素,二甲双胍水平之间的关系,血液pH值,血清碳酸氢盐,乳酸水平和呼吸机依赖的临床结果,肾脏替代疗法的需求,急性肾损伤(AKI)患者的肾脏恢复,和生存。
结果:共107例患者的二甲双胍水平,其中19例符合MALA诊断标准。在我们的案例系列中,MALA主要见于继发于脱水和败血症的AKI(15例),其次是终末期肾病(ESRD)(4例)。17例患者需要插管,其中8人在平均持续时间14天后成功拔管。16例患者接受肾脏替代治疗(RRT)。间歇性血液透析(IHD)进行了9,连续肾脏替代疗法(CRRT)在四个,3例患者采用IHD和CRRT序贯治疗。七个病人,全部在AKI组(46.7%),所有ESRD患者都存活下来,占总死亡率的36.8%。在八名幸存的AKI患者中,4人肾脏完全恢复,肾功能恢复至基线,三个人的肾脏部分恢复,其中一人在出院到康复设施时继续需要IHD。
结论:MALA可能是一个未被认可的实体。高度的临床怀疑导致RRT迅速和积极治疗可能会提高死亡率。提供者和患者的教育对于二甲双胍的安全使用至关重要。
BACKGROUND: Metformin is widely considered a first-line antiglycemic agent due to its cost-effectiveness and favorable adverse effect profile. However, its use is prohibited in patients with an estimated glomerular filtration rate <30 mL/min/1.73 m2 , due to the risk of potentially lethal metformin-associated lactic acidosis (MALA). We sought to evaluate MALA cases and outcomes at our institution.
METHODS: In this observational, retrospective
case series, we reviewed our EMR for all patients who had a metformin level drawn between January 2013 and May 2022 to identify individuals who met the diagnostic criteria for MALA. We evaluated risk factors for MALA, the relationship between metformin level, blood pH, serum bicarbonate, and lactate level and clinical outcomes of ventilator dependency, renal replacement therapy requirement, renal recovery in acute kidney injury (AKI) patients, and survival.
RESULTS: A total of 107 patients had metformin levels drawn, of which 19 patients met the diagnostic criteria for MALA. In our
case series, MALA was primarily seen in AKI (15 patients) secondary to dehydration and sepsis, followed by end-stage renal disease (ESRD) (4 patients). Intubation was required in 17 patients, of whom 8 were successfully extubated after a mean duration of 14 days. Sixteen patients received renal replacement therapy (RRT). Intermittent hemodialysis (IHD) was performed in nine, continuous renal replacement therapy (CRRT) in four, and sequential therapy of IHD and CRRT in three patients. Seven patients, all in the AKI group (46.7%), died while all ESRD patients survived, accounting for an overall mortality rate of 36.8%. Among the eight surviving AKI patients, four had complete renal recovery with renal function returning to baseline, three had partial renal recovery, and one continued to require IHD at the time of discharge to a rehabilitation facility.
CONCLUSIONS: MALA may be an underrecognized entity. A high level of clinical suspicion leading to prompt and aggressive treatment with RRT may improve mortality rates. Provider and patient education is of paramount importance for safe use of metformin.