SHM Converge Scientific Abstract ePoster Gallery-Silent Sabotage Chronic Iatrogenic Metformin Associated Lactic Acidosis Causing Acute Renal Failure

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This presentation describes a fatal case of metformin-induced lactic acidosis (MILA) in an 84-year-old man with chronic kidney disease and prediabetes. He was transferred from a low-resource facility with altered mental status after recent surgery for perforated diverticulitis complicated by abscesses. On arrival, he had severe acute kidney injury (creatinine 5.54 from a baseline of 0.72), hyperkalemia, metabolic acidosis, and elevated lactate. Imaging did not show obstruction or hydronephrosis.<br /><br />Collateral history revealed that he had recently been started on metformin 500 mg daily, then increased to 500 mg twice daily, and had also received furosemide. He had poor oral intake and worsening kidney function, progressing from KDIGO stage 1 to stage 3 AKI before presentation. His lactate peaked at 12.4, the anion gap rose to 32, and he required vasopressors, hemodialysis, and continuous renal replacement therapy. Blood cultures were negative, making infection less likely as the primary cause.<br /><br />Metformin levels were markedly elevated before dialysis (22 mcg/mL; therapeutic range 1–2 mcg/mL) and decreased after treatment. Despite two weeks of intensive care, the patient transitioned to comfort care, was discharged to hospice, and died.<br /><br />The presentation reviews that metformin-associated lactic acidosis is rare but serious, with risk increased by renal dysfunction, dehydration, nephrotoxin exposure, and poor intake. It emphasizes prevention: careful patient selection when starting metformin, close monitoring of renal function, avoidance of nephrotoxins, and rapid treatment of acute kidney injury. In vulnerable patients, especially in low-resource settings, clinicians should weigh the practical tradeoffs between insulin and metformin and act quickly when renal failure or lactic acidosis develops.

Asset Subtitle

Phong Truong

Meta Tag

Author List Natasha Tobarran, Phong Truong

Category Clinical Vignettes

Concept Metformin-Associated Lactic Acidosis

Concept Lactic Acidosis

Concept Metformin

Concept Acute Kidney Injury

Concept Dialysis

Distinguished Non-Finalist

Presenter Organization Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland

Presenting Author Phong Truong

Track Adult

Keywords

metformin-induced lactic acidosis

MILA

acute kidney injury

chronic kidney disease

lactic acidosis

hemodialysis

continuous renal replacement therapy

metformin toxicity

hyperkalemia

renal failure

Metformin-Associated Lactic Acidosis

Lactic Acidosis

Metformin

Acute Kidney Injury

Dialysis