Linezolid-Associated Lactic Acidosis Requiring Intermittent Hemodialysis and Continuous Renal Replacement Therapy: A Case Report

Introduction: Linezolid, an oxazolidinone antibiotic used for multidrug-resistant gram-positive infections and drug-resistant tuberculosis, has been associated with rare but potentially fatal lactic acidosis due to mitochondrial toxicity. Kidney replacement therapy (KRT) has been utilized for lactate clearance and linezolid elimination, although its role and utility remain incompletely defined. Case Description: We report a case of a 75-year-old male with history of pulmonary tuberculosis on prolonged linezolid therapy who developed severe type B lactic acidosis (lactate 20.0 mmol/L) without hemodynamic instability. Following initial correction with two sessions of intermittent hemodialysis (IHD), rebound lactate elevation necessitated transition to continuous renal replacement therapy (CRRT). Sustained lactate clearance and metabolic stabilization were achieved after 30.8 hours of CRRT, without requiring vasopressors or additional organ support. Infectious and ischemic causes were excluded. Discussion: This case highlights a unique sequential KRT approach in the management of linezolid-induced lactic acidosis in a hemodynamically stable patient. Despite partial dialyzability of linezolid, lactate rebound following IHD suggests ongoing mitochondrial dysfunction and redistribution of lactate given its high volume of distribution, necessitating prolonged clearance through CRRT. Our findings emphasize the importance of early recognition of toxicity and tailored KRT strategies based on clinical trajectory rather than hemodynamic status alone.Laboratory data from hospitalization days 1-6. Numbers in parentheses indicate hours since KRT initiation.Lactate over time following IHD and CRRT.