We report two cases of severe lactic acidosis due to massive metformin ingestion. The first case was a 37-year-old man who was discovered several hours after ingesting 45 g of metformin. He had severe lactic acidosis (blood pH 6.81, bicarbonate 4 mEq/L, lactate 25.7 mEq/L). Despite intravenous bicarbonate therapy, he decompensated and was placed on a combination of hemodialysis and charcoal hemoperfusion for a continuous time of 25 hours. His hospital course was complicated by acute renal failure requiring a period of intermittent hemodialysis. He has since made a complete recovery. The second case was a 53-year-old man who ingested 50 g of metformin. He also presented with severe lactic acidosis (blood pH 6.85, bicarbonate 3 mEq/L and lactate 28.4 mEq/L) and deteriorated despite intravenous bicarbonate therapy. He was placed on hemodialysis as a continuous therapy for 21 hours. His hospital course was complicated by acute renal failure requiring a period of intermittent hemodialysis. He has subsequently made a complete recovery. Metformin-associated lactic acidosis carries a high mortality rate. Prolonged hemodialysis should be considered as an early treatment option in these cases.

Metformin is commonly used in diabetes mellitus type 2, with lactic acidosis being a rare but potentially fatal complication of this therapy. The management of metformin-associated lactic acidosis (MALA) is controversial. Treatment may include supportive care, activated charcoal, bicarbonate infusion, hemodialysis, or continuous venovenous hemofiltration. In the previous issue of Critical Care, Peters and colleagues systematically evaluated outcomes in MALA patients admitted to their intensive care unit. The mortality rate of patients who received dialysis was similar to that of patients who were not dialyzed. However, it was the more acutely and chronically ill patients who actually received dialysis. This suggests that hemodialysis was beneficial in preventing a higher mortality rate in those who required renal replacement therapy.The literature on the management of metformin-associated lactic acidosis (MALA) is sparse and consists of case reports and case series. In the previous issue of Critical Care, Peters and colleagues [1] presented a retrospective cohort study in patients with MALA. This study represents an important step forward in systematically evaluating outcomes in this rare but serious condition.Metformin is commonly used in type 2 diabetes mellitus and accounts for approximately one third of all prescriptions for oral hypoglycemic agents in the US [2]. The United Kingdom Prospective Diabetes Study demonstrated impressive reductions in diabetes-related endpoints and mortality in overweight patients with type 2 diabetes who used this drug [3]. A rare but extremely serious adverse effect of this medication is lactic acidosis, which carries a staggering 50% mortality rate [4].Metformin is renally cleared and is known to accumulate in patients with chronic kidney disease [4]. Current guidelines stipulate that it be used with caution in estimated glomerular filtration rates (eGFRs) of less than 60 mL/minute and not at all in eGFRs of less than 30 mL/minute [5]. Identified risk factors for MALA include acute kidney injury (AKI), hypoxemia, sepsis, alcohol abuse, liver failure, myocardial infarction, and shock [6]. Medications that interfere with renal hemodynamic autoregulation (that is, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and nonsteroidal anti-inflammatory drugs) and volume depletion are frequently implicated in generating the AKI leading to MALA [4]. The incidence of MALA is quoted at 1 to 5 cases per 100,000 patient-years but may be as high as 30 cases per 100,000 patient-years [4].The mainstay of MALA therapy is supportive care. Particular attention should be paid to normalizing the acid-base imbalance, eliminating offending medication, and treating concomitant disease [4]. Activated charcoal may also have a role, especially in cases of metformin overdose [6]. Intravenous sodium bicarbonate is commonly used to correct blood pH. Renal replacement therapies, including conventional hemodialysis and continuous venovenous hemofiltration, have been successfully...

Background: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. Methods: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient’s care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. Results: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0–2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29–3.62), while longer dialysis vintage was ­associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95–0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. Conclusion: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.

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