Kidney Week

Abstract: SA-PO508

Metformin Toxicity and Euglycemic DKA: A Tale of Two Acidosis

Session Information

• Acid-Base, Calcium, Potassium, and Magnesium Disorders: Clinical
  October 26, 2024 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Yelamanchi, Aditya, University of California Davis, Davis, California, United States

Aditya Yelamanchi, DO

• Vuyyuru, Sharmilee, University of California Davis, Davis, California, United States

Sharmilee Vuyyuru, DO

• Chau, Andrea, University of California Davis, Davis, California, United States

Andrea Chau, MD

• Nguyen, Amanda, University of California Davis, Davis, California, United States

Amanda Nguyen, MD

• Young, Brian Y., University of California Davis, Davis, California, United States

Brian Y. Young, MD, FASN

Introduction

^{Metformin associated lactic acidosis (MALA) and euglycemic diabetic ketoacidosis (euDKA) from SGLT2 inhibitor use are well known life-threatening metabolic disorders where immediate recognition and treatment is imperative to decrease mortality in patients. However, MALA and euDKA have rarely been cited in literature to occur simultaneously, as seen in our case.}

Case Description

^{A 60 year old male with chronic kidney disease stage 3B, diabetes mellitus with retinopathy and peripheral neuropathy was admitted from a nursing facility with altered mental status, abdominal pain, decreased oral intake, and emesis. History was limited on admission. He was found to have a severe anion gap metabolic acidosis and anuric acute kidney injury. Admission creatinine was 10.06mg/dL (baseline ~ 2), serum bicarbonate level was 10mmol/l, anion gap was 44mmol/L, blood glucose was 154mg/dL, and pH on venous blood gas was 7.17. Nephrology was consulted, which prompted a more extensive workup revealing urinalysis with trace ketones and many granular casts, serum beta-hydroxybutyrate level at 6.84mmol/L, and lactic acid level at 6.4mmol/L. This combination of findings was concerning for dual euglycemic DKA and metformin toxicity. Given the high mortality of untreated metformin toxicity, empiric emergent hemodialysis was initiated. Post 2 dialysis treatments, there was significant renal recovery, with creatinine stabilizing at 2.2mg/dL and normalization of lactic acid. It was later found that the patient was taking both metformin 500mg bid and empagliflozin 10mg daily before admission. Metformin level sent prior to dialysis returned 2 weeks later at 23mcg/mL (therapeutic range 1-2; toxic level 5).}

Discussion

^{MALA is a rare and lethal diagnosis with mortality rates ranging from 25-50%, without a significant correlation between degree of acidosis. While concurrent euDKA and MALA is rare, this scenario should be considered given increasing use of both agents. When clinical suspicion is high for this dual acidosis, waiting on serum metformin levels should not delay dialysis given the high mortality. Treatment of euDKA should also be initiated simultaneously.}