12388 MALA: A Severe Nonfatal Case Report

Abstract Disclosure: J.M. Matos-Chaparro: None. V. Martinez-Aponte: None. S. Velez-Maymi: None. Metformin associated lactic acidosis (MALA) is defined as altered lactate and hydrogen metabolism with pH <7.35, lactate >5 mmol/L in a patient using metformin chronically or with an overdose. MALA carries a significant mortality rate of up to 50% in metformin consumers. This is a case report of a severe non-fatal MALA that responded successfully to renal replacement therapy. We report the case of a 83-year-old female with past medical history of DMT2 and hypertension, who arrived at the urgency room due to anuria and non-radiating, lower back pain, 9/10 in intensity, with associated anorexia and general weakness, of two days of evolution. Review of systems was negative for nauseas, vomiting, and urinary symptoms. Medical reconciliation remarkable for metformin 1000 mg orally daily and losartan 100 mg orally daily. Patient was admitted to the ICU after chemistry remarkable for creatinine 6.25 mg/dL and BUN 85 mg/dL (CrCl 7 ml/min and GFR 6 ml/min). Creatine level more than 3-fold of her baseline (1.20 mg/dL). Electrolyte disturbances remarkable for severe hyperkalemia 7.30 mmol/L with peaked T waves on EKG, isotonic moderate hyponatremia (Na 128 mmol/L) and a pronounced acidosis (pH 7.28, pCO2 35, HCO3 16.20). Also, a hyperlactatemia of 9.8 mmol/L. Despite discontinuation of metformin and aggressive fluids therapy the patient progress to an oliguric state with worsening renal function (creatine 7.08 mg/dL). As per nephrology recommendations emergent renal replacement therapy was initiated. Patient underwent three consecutive days of hemodialysis that resulted in a significant improvement of renal function as well as resolution of electrolyte disturbances. The patient was transitioned to subcutaneous (Lantus) and oral therapy (Tradjenta) for DMT2 outpatient management. This case illustrates the potential for severe lactic acidosis induced by metformin toxicity. Even though most patients respond to aggressive fluid therapy and discontinuation of medication, in this case emergency hemodialysis was indicated as patient with multiple electrolyte disturbances and oliguric state. Measurements of biological parameters blood concentrations showed the effectiveness of repeated hemodialysis sessions on metformin elimination and acidosis. Patient admission was shortened due to early recognition and prompt initiation of hemodialysis, reducing hospital associated complications and cost. MALA is a fatal complication commonly seen on elderly patients on high doses of metformin. Accurate recognition and prompt initiation of dialysis and close observation in an intensive care unit leads to rapid recovery and favorable outcomes. On literature review, most cases reported with severe MALA were associated with a high mortality rate. This is a severe case of MALA with a favorable outcome due to prompt recognition and treatment with renal replacement therapy. Presentation: 6/1/2024