Acute Kidney Injury Precipitating Metformin-associated Lactic Acidosis: Clinical Presentation and Management

Metformin is a frequently prescribed oral hypoglycemic drug for type 2 diabetes mellitus.While its positive effect is to control glucose level in the body, it also reduces the clearance of lactate by inhibiting mitochondrial oxidative phosphorylation, leading to the risk of lactate accumulation.Metformin-associated lactic acidosis (MALA) is a rare but serious side effect reported in patients taking metformin.Patients at risk are those with kidney/liver/heart disease, dehydrated, or acutely ill.It can be treated by stopping metformin, fluid resuscitation, and/or renal replacement therapy.However, its mortality rate ranges from 30 to 50%.Here, we discuss a 52-year-old diabetic patient who was on a regular dose of metformin for the last 7 years and visited our emergency department with symptoms of MALA.The patient was doing Kriya (13 days of afterdeath rituals), where he was not hydrated enough and was vomiting, which acts as a precipitating factor for MALA.His arterial blood gas (ABG) analysis showed high anion gap lactic acidosis (pH: 6.57, lactate: 12 mmol/L), and blood reports revealed acute kidney injury and hyperkalemia.His urine for ketone was negative, vitals (except being tachypneic), total blood count, and liver function test were normal, which ruled out other possible causes (ketoacidosis, sepsis, liver disease) of metabolic acidosis.The patient was admitted to the ICU and underwent three sessions of hemodialysis (one emergency + one session each in the next two days).It is important to use metformin with caution in high-risk patients.