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MALA Emergency Dialysis — ESENeph MCQ

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HardAcute Kidney InjuryMALA Emergency DialysisESENeph

A 61-year-old woman with type 2 diabetes develops AKI while on metformin (creatinine rises from 120 to 380 umol/L). She presents with severe nausea, vomiting, and Kussmaul breathing. ABG: pH 7.05, lactate 14 mmol/L, bicarbonate 5 mmol/L. Glucose is 8.2 mmol/L. What is the priority management alongside stopping metformin?

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Correct answer: B — Emergency haemodialysis as the next step

Metformin-associated lactic acidosis (MALA) in the setting of AKI is a medical emergency. With pH 7.05 and lactate 14 mmol/L, this is severe lactic acidosis. Emergency haemodialysis (or CVVHDF if haemodynamically unstable) is the treatment of choice — it removes metformin (small molecule, low protein binding, high water solubility), corrects acidosis via bicarbonate-based dialysate, and addresses the AKI. IV sodium bicarbonate may be used as a temporising measure but does not remove metformin. Metformin inhibits mitochondrial complex I, causing anaerobic glycolysis and lactate accumulation, which is normally cleared renally.

Reference: https://guidelines.ukkidney.org