Akut Böbrek Hasarı Olgusunda Metformin İle İlişkili Laktik Asidoz

Abstract

Metformin, tip 2 diyabetin birinci basamak tedavisinde önerilen bir oral anti-diyabetik ajandır. Laktik asidoz, nadir gözlenmekle birlikte, yüksek mortalite oranı nedeniyle ilacın en önemli yan etkisidir. Hipoksemi, sepsis, akut ve kronik böbrek hasarı, karaciğer yetmezliği ve kalp yetmezliği metformin ilişkili laktik asidoz (MALA) gelişimini kolaylaştırabilir. MALA’da erken tanı ve uygun tedavi morbidite ve mortaliteyi azaltmaktadır. 64 yaşındaki kadın hasta parkinsonizm bulguları nedeniyle nöroloji servisinde takip edilmekteyken üre kreatinin yüksekliği olması üzerine konsülte edildi. Bulantı kusma ve iştahsızlık şikayeti vardı. Vital bulguları stabildi. Sorgulandığında 6 senedir diyabetes mellitus için metformin tedavisi aldığı öğrenildi. Kan gazında artmış anyon açıklı metabolik asidoz ve laktik asit yüksekliği saptandı. Hastada akut böbrek hasarı zemininde gelişen MALA düşünülerek metformin kesildi. Hemodiyalize alındı ve destek tedavi uygulandı. Hastanın böbrek fonksiyonları 1 hafta sonra normale döndü.

Keywords

• akut böbrek hasarı
• metformin
• laktik asidoz
• hemodiyaliz

Metformin-associated Lactic Acidosis in a Case of Acute Kidney Injury

Abstract

Metformin is an oral anti-diabetic agent recommended in the first-line treatment of type 2 diabetes. Although lactic acidosis is rarely observed, it is the most important side effect due to its high mortality rate. Hypoxemia, sepsis, acute and chronic renal injury, hepatic insufficiency and heart failure can precipitate metformin-associated lactic acidosis (MALA). Early diagnosis and appropriate treatment reduce morbidity and mortality in MALA. A 64-year-old female patient was hospitalized in the neurology department due to signs of parkinsonism and was consulted due to increased urea and creatinine. She had nausea, vomiting and loss of appetite. Her vital signs were stable. When questioned, it was learned that she had been receiving metformin treatment for diabetes mellitus for 6 years. High anion gap metabolic acidosis and lactic acid elevation were found in blood gas. The patient was considered to have MALA in the setting of acute kidney injury. Metformin was discontinued. Hemodialysis and supportive treatment was administered. Recovery of the patient's renal functions was achieved after a week.

Keywords

• acute kidney injury
• metformin
• lactic acidosis
• hemodialysis

References

1. American Diabetes Association. 9. Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetesd―2020. Diabetes Care. 2020;43(supplement 1):98–110.
2. Defronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: Current perspectives on causes and risk. Metabolism. 2016;65(2):20–9.
3. Eppenga WL, Lalmohamed A, Geerts AF, Derijks HJ, Wensing M, Egberts A, De Smet PA, de Vries F. Risk of lactic acidosis or elevated lactate concentrations in metformin users with renal impairment: A population-based cohort study. Diabetes Care. 2014;37(8):2218–24.
4. Kajbaf F, Lalau JD. Mortality rate in so-called “metformin-associated lactic acidosis”: A review of the data since the 1960s. Pharmacoepidemiol Drug Saf. 2014;23(11):1123–7.
5. Graham GG, Punt J, Arora M, Day RO, Doogue MP, Duong JK, Furlong TJ, Greenfield JR, Greenup LC, Kirkpatrick CM, Ray JE, Timmins P, Williams KM. Clinical pharmacokinetics of metformin. Clin Pharmacokinet. 2011;50(2):81–98.
6. Lalau JD. Lactic acidosis induced by metformin: Incidence, management and prevention. Drug Saf. 2010;33(9):727–40.
7. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2010;2010(4):CD002967.
8. Kuan IHS, Savage RL, Duffull SB, Walker RJ, Wright DFB. The Association between Metformin Therapy and Lactic Acidosis. Drug Saf. 2019;42(12):1449–69.

9. Finkle SN. Should dialysis be offered in all cases of metformin-associated lactic acidosis? Crit Care. 2009;13(1):110.
10. Balkan B, Demir G, Balkan F, Çetingök H, Atiç E. Metformin İlişkili Laktik Asidoz; Bir Olgu Nedeni ile Literatürün Gözden Geçirilmesi. Tıp Fakültesi Klin Derg. 2020;3(1):49–53.