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See KC. Metformin-associated lactic acidosis: A mini review of pathophysiology, diagnosis and management in critically ill patients. World J Diabetes 2024; 15:1178-1186. [PMID: 38983827 PMCID: PMC11229964 DOI: 10.4239/wjd.v15.i6.1178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 04/04/2024] [Accepted: 04/23/2024] [Indexed: 06/11/2024] Open
Abstract
Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation, leading to metformin-associated lactic acidosis (MALA). As diabetes mellitus is a common chronic metabolic condition found in critically ill patients, pre-existing metformin use can often be found in critically ill patients admitted to the intensive care unit or the high dependency unit. The aim of this narrative mini review is therefore to update clinicians about MALA, and to provide a practical approach to its diagnosis and treatment. MALA in critically ill patients may be suspected in a patient who has received metformin and who has a high anion gap metabolic acidosis, and confirmed when lactate exceeds 5 mmol/L. Risk factors include those that reduce renal elimination of metformin (renal impairment from any cause, histamine-2 receptor antagonists, ribociclib) and excessive alcohol consumption (as ethanol oxidation consumes nicotinamide adenine dinucleotides that are also required for lactate metabolism). Treatment of MALA involves immediate cessation of metformin, supportive management, treating other concurrent causes of lactic acidosis like sepsis, and treating any coexisting diabetic ketoacidosis. Severe MALA requires extracorporeal removal of metformin with either intermittent hemodialysis or continuous kidney replacement therapy. The optimal time to restart metformin has not been well-studied. It is nonetheless reasonable to first ensure that lactic acidosis has resolved, and then recheck the kidney function post-recovery from critical illness, ensuring that the estimated glomerular filtration rate is 30 mL/min/1.73 m2 or better before restarting metformin.
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Affiliation(s)
- Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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Yarimizu K, Onodera Y, Suzuki H, Nakane M, Kawamae K. Changes in oxygen supply-demand balance during induction of general anesthesia: an exploratory study using remimazolam. J Anesth 2024:10.1007/s00540-024-03362-0. [PMID: 38842681 DOI: 10.1007/s00540-024-03362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/31/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE This study was performed to evaluate the changes in oxygen supply-demand balance during induction of general anesthesia using an indirect calorimeter capable of measuring oxygen consumption (VO2) and carbon dioxide production (VCO2). METHODS This study included patients scheduled for surgery in whom remimazolam was administered as a general anesthetic. VO2 and VCO2 were measured at different intervals: upon awakening (T1), 15 min after tracheal intubation (T2), and 1 h after T2 (T3). Oxygen delivery (DO2) was calculated simultaneously with these measurements. VO2 was ascertained using an indirect calorimeter and further calculated using vital signs, among other factors. DO2 was derived from cardiac output and arterial blood gas analysis performed with an arterial pressure-based cardiac output measurement system. RESULTS VO2, VCO2, and DO2 decreased significantly from T1 to T2 and T3 [VO2/body surface area (BSA) (ml/min/m2): T1, 130 (122-146); T2, 107 (83-139); T3, 97 (93-121); p = 0.011], [VCO2/BSA (ml/min/m2): T1, 115 (105-129); T2, 90 (71-107); T3, 81 (69-101); p = 0.011], [DO2/BSA (ml/min/m2): T1, 467 (395-582); T2, 347 (286-392); T3, 382 (238-414); p = 0.0020]. Among the study subjects, a subset exhibited minimal reduction in VCO2. Although the respiratory frequency was titrated on the basis of end-tidal CO2 levels, there was no significant difference between the groups. CONCLUSION General anesthetic induction with remimazolam decreased VO2, VCO2, and DO2.
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Affiliation(s)
- Kenya Yarimizu
- Department of Anesthesiology, Yamagata University Hospital, 2-2-2 Iida-Nishi, Yamagata, Yamagata, 990-9585, Japan.
| | - Yu Onodera
- Department of Anesthesiology, Yamagata University Hospital, 2-2-2 Iida-Nishi, Yamagata, Yamagata, 990-9585, Japan
| | | | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata, Japan
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Baskal S, Posma RA, Bollenbach A, Dieperink W, Bakker SJL, Nijsten MW, Touw DJ, Tsikas D. GC-MS analysis of 4-hydroxyproline: elevated proline hydroxylation in metformin-associated lactic acidosis and metformin-treated Becker muscular dystrophy patients. Amino Acids 2024; 56:21. [PMID: 38461423 PMCID: PMC10925573 DOI: 10.1007/s00726-024-03383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 01/31/2024] [Indexed: 03/12/2024]
Abstract
Metformin (N,N-dimethylbiguanide), an inhibitor of gluconeogenesis and insulin sensitizer, is widely used for the treatment of type 2 diabetes. In some patients with renal insufficiency, metformin can accumulate and cause lactic acidosis, known as metformin-associated lactic acidosis (MALA, defined as lactate ≥ 5 mM, pH < 7.35, and metformin concentration > 38.7 µM). Here, we report on the post-translational modification (PTM) of proline (Pro) to 4-hydroxyproline (OH-Pro) in metformin-associated lactic acidosis and in metformin-treated patients with Becker muscular dystrophy (BMD). Pro and OH-Pro were measured simultaneously by gas chromatography-mass spectrometry before, during, and after renal replacement therapy in a patient admitted to the intensive care unit (ICU) because of MALA. At admission to the ICU, plasma metformin concentration was 175 µM, with a corresponding lactate concentration of 20 mM and a blood pH of 7.1. Throughout ICU admission, the Pro concentration was lower compared to healthy controls. Renal excretion of OH-Pro was initially high and decreased over time. Moreover, during the first 12 h of ICU admission, OH-Pro seems to be renally secreted while thereafter, it was reabsorbed. Our results suggest that MALA is associated with hyper-hydroxyprolinuria due to elevated PTM of Pro to OH-Pro by prolyl-hydroxylase and/or inhibition of OH-Pro metabolism in the kidneys. In BMD patients, metformin, at the therapeutic dose of 3 × 500 mg per day for 6 weeks, increased the urinary excretion of OH-Pro suggesting elevation of Pro hydroxylation to OH-Pro. Our study suggests that metformin induces specifically the expression/activity of prolyl-hydroxylase in metformin intoxication and BMD.
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Affiliation(s)
- Svetlana Baskal
- Institute of Toxicology, Core Unit Proteomics, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Rene A Posma
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alexander Bollenbach
- Institute of Toxicology, Core Unit Proteomics, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dimitrios Tsikas
- Institute of Toxicology, Core Unit Proteomics, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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Brunoni B, Zadek F, Protti A, Cecconi M, Fumagalli R, Langer T. Uncomplicated Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in 2 Other Patients with Metformin Accumulation. Blood Purif 2024; 53:591-593. [PMID: 38346416 DOI: 10.1159/000537712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/06/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Beatrice Brunoni
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Milan, Italy
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Brunoni B, Zadek F, Mulazzani F, Verza G, Marrazzo F, Spina S, Protti A, Fumagalli R, Langer T. Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review. Blood Purif 2023; 52:802-811. [PMID: 37673054 DOI: 10.1159/000531953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/29/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Metformin intoxication causes lactic acidosis by inhibiting Krebs' cycle and oxidative phosphorylation. Continuous renal replacement therapy (CRRT) is recommended for metformin removal in critically ill patients. According to current guidelines, regional citrate anticoagulation (RCA) is the first-line strategy. However, since metformin also inhibits citrate metabolism, a risk of citrate accumulation could be hypothesized. In the present study, we monitored the potential citrate accumulation in metformin-associated lactic acidosis (MALA) patients treated with CRRT and RCA using the physical-chemical approach to acid-base interpretation. METHODS We collected a case series of 3 patients with MALA. Patients were treated with continuous venovenous hemofiltration (CVVH), and RCA was performed with diluted citrate solution. Citrate accumulation was monitored through two methods: the ratio between total and ionized plasma calcium concentrations (T/I calcium ratio) above 2.5 and the strong ion gap (SIG) to identify an increased concentration of unmeasured anions. Lastly, a mathematical model was developed to estimate the expected citrate accumulation during CVVH and RCA. RESULTS All 3 patients showed a resolution of MALA after the treatment with CVVH. The T/I calcium ratio was consistently below 2.5, and SIG decreased, reaching values lower than 6 mEq/L after 48 h of CVVH treatment. According to the mathematical model, the estimated SIG without citrate metabolism should have been around 21 mEq/L due to citrate accumulation. CONCLUSIONS In our clinical management, no signs of citrate accumulation were recorded in MALA patients during treatment with CVVH and RCA. Our data support the safe use of diluted citrate to perform RCA during metformin intoxication.
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Affiliation(s)
- Beatrice Brunoni
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesca Mulazzani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giovanni Verza
- INFN, Sezione di Padova, Padova, Italy
- Dipartimento di Fisica e Astronomia "G. Galilei", Università Degli Studi di Padova, Padova, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Stefano Spina
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
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Goonoo MS, Morris R, Raithatha A, Creagh F. Republished: Metformin-associated lactic acidosis: reinforcing learning points. Drug Ther Bull 2021; 59:124-127. [PMID: 34031180 DOI: 10.1136/dtb.2021.235608rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Mohummad Shaan Goonoo
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Morris
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ajay Raithatha
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fionuala Creagh
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Increased ratio of P[v-a]CO 2 to C[a-v]O 2 without global hypoxia: the case of metformin-induced lactic acidosis. Respir Physiol Neurobiol 2020; 285:103586. [PMID: 33202296 DOI: 10.1016/j.resp.2020.103586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/18/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022]
Abstract
The ratio of venoarterial CO2 tension to arteriovenous O2 content difference (P[v-a]CO2/C[a-v]O2) increases when lactic acidosis is due to inadequate oxygen supply (hypoxia); we aimed to verify whether it also increases when lactic acidosis develops because of mitochondrial dysfunction (dysoxia) with constant oxygen delivery. Twelve anaesthetised, mechanically ventilated pigs were intoxicated with IV metformin (4.0 to 6.4 g over 2.5 to 4.0 h). Saline and norepinephrine were used to preserve oxygen delivery. Lactate and P[v-a]CO2/C[a-v]O2 were measured every one or two hours (arterial and mixed venous blood). During metformin intoxication, lactate increased from 0.8 (0.6-0.9) to 8.5 (5.0-10.9) mmol/l (p < 0.001), even if oxygen delivery remained constant (from 352 ± 78 to 343 ± 97 ml/min, p = 0.098). P[v-a]CO2/C[a-v]O2 increased from 1.6 (1.2-1.8) to 2.3 (1.9-3.2) mmHg/ml/dl (p = 0.004). The intraclass correlation coefficient between lactate and P[v-a]CO2/C[a-v]O2 was 0.72 (p < 0.001). We conclude that P[v-a]CO2/C[a-v]O2 increases when lactic acidosis is due to dysoxia. Therefore, a high P[v-a]CO2/C[a-v]O2 may not discriminate hypoxia from dysoxia as the cause of lactic acidosis.
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Metformin-Induced Lactic Acidosis: A Question of Time. Case Rep Crit Care 2020; 2020:6962591. [PMID: 33145113 PMCID: PMC7596499 DOI: 10.1155/2020/6962591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 08/01/2020] [Accepted: 10/14/2020] [Indexed: 12/03/2022] Open
Abstract
Metformin is an oral antidiabetic largely prescribed in the treatment of type II diabetes. Overdose is associated with life-threatening lactic acidosis. We report the case of the highest metformin concentration ever described secondary to a voluntary suicidal intake. The patient developed a severe lactic acidosis and hemodynamic shock successfully treated with high-flow hemofiltration. Time to start extrarenal epuration is capital to avoid poor evolution.
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Goonoo MS, Morris R, Raithatha A, Creagh F. Metformin-associated lactic acidosis: reinforcing learning points. BMJ Case Rep 2020; 13:e235608. [PMID: 32878828 PMCID: PMC7470503 DOI: 10.1136/bcr-2020-235608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 11/03/2022] Open
Abstract
Metformin-associated lactic acidosis (MALA) carries a high mortality rate. It is seen in patients with type 2 diabetes on metformin or patients who attempt suicide with metformin overdose. We present the case of a man in his early 20s with type 2 diabetes, hypertension and hypothyroidism who presented with agitation, abdominal pain and vomiting after ingesting 50-60 g of metformin; he developed severe lactic acidosis (blood pH 6.93, bicarbonate 7.8 mEq/L, lactate 28.0 mEq/L). He was managed with intravenous 8.4% bicarbonate infusion and continuous venovenous haemodiafiltration. He also developed acute renal failure (ARF) requiring intermittent haemodialysis and continuous haemodiafiltration. MALA is uncommon and causes changes in different vital organs and even death. The primary goals of therapy are restoration of acid-base status and removal of metformin. Early renal replacement therapy for ARF can result in rapid reversal of the acidosis and good recovery, even with levels of lactate normally considered to be incompatible with survival.
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Affiliation(s)
- Mohummad Shaan Goonoo
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Morris
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ajay Raithatha
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fionuala Creagh
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Posma RA, Venema LH, Huijink TM, Westerkamp AC, Wessels AMA, De Vries NJ, Doesburg F, Roggeveld J, Ottens PJ, Touw DJ, Nijsten MW, Leuvenink HGD. Increasing metformin concentrations and its excretion in both rat and porcine ex vivo normothermic kidney perfusion model. BMJ Open Diabetes Res Care 2020; 8:8/1/e000816. [PMID: 32816871 PMCID: PMC7437879 DOI: 10.1136/bmjdrc-2019-000816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 05/12/2020] [Accepted: 06/12/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Metformin can accumulate and cause lactic acidosis in patients with renal insufficiency. Metformin is known to inhibit mitochondria, while renal secretion of the drug by proximal tubules indirectly requires energy. We investigated whether addition of metformin before or during ex vivo isolated normothermic machine perfusion (NMP) of porcine and rat kidneys affects its elimination. RESEARCH DESIGN AND METHODS First, Lewis rats were pretreated with metformin or saline the day before nephrectomy. Subsequently, NMP of the kidney was performed for 90 min. Metformin was added to the perfusion fluid in one of three different concentrations (none, 30 mg/L or 300 mg/L). Second, metformin was added in increasing doses to the perfusion fluid during 4 hours of NMP of porcine kidneys. Metformin concentration was determined in the perfusion fluid and urine by liquid chromatography-tandem mass spectrometry. RESULTS Metformin clearance was approximately 4-5 times higher than creatinine clearance in both models, underscoring secretion of the drug. Metformin clearance at the end of NMP in rat kidneys perfused with 30 mg/L was lower than in metformin pretreated rats without the addition of metformin during perfusion (both p≤0.05), but kidneys perfused with 300 mg/L trended toward lower metformin clearance (p=0.06). Creatinine clearance was not different between treatment groups. During NMP of porcine kidneys, metformin clearance peaked at 90 min of NMP (18.2±13.7 mL/min/100 g). Thereafter, metformin clearance declined, while creatinine clearance remained stable. This observation can be explained by saturation of metformin transporters with a Michaelis-Menten constant (95% CI) of 23.0 (10.0 to 52.3) mg/L. CONCLUSIONS Metformin was secreted during NMP of both rat and porcine kidneys. Excretion of metformin decreased under increasing concentrations of metformin, which might be explained by saturation of metformin transporters rather than a self-inhibitory effect. It remains unknown whether a self-inhibitory effect contributes to metformin accumulation in humans with longer exposure times.
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Affiliation(s)
- Rene A Posma
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Leonie H Venema
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tobias M Huijink
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andrie C Westerkamp
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A Mireille A Wessels
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nynke J De Vries
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frank Doesburg
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Roggeveld
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Petra J Ottens
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Posma RA, Frøslev T, Jespersen B, van der Horst ICC, Touw DJ, Thomsen RW, Nijsten MW, Christiansen CF. Prognostic impact of elevated lactate levels on mortality in critically ill patients with and without preadmission metformin treatment: a Danish registry-based cohort study. Ann Intensive Care 2020; 10:36. [PMID: 32219580 PMCID: PMC7098407 DOI: 10.1186/s13613-020-00652-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/16/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Lactate is a robust prognostic marker for the outcome of critically ill patients. Several small studies reported that metformin users have higher lactate levels at ICU admission without a concomitant increase in mortality. However, this has not been investigated in a larger cohort. We aimed to determine whether the association between lactate levels around ICU admission and mortality is different in metformin users compared to metformin nonusers. METHODS This cohort study included patients admitted to ICUs in northern Denmark between January 2010 and August 2017 with any circulating lactate measured around ICU admission, which was defined as 12 h before until 6 h after admission. The association between the mean of the lactate levels measured during this period and 30-day mortality was determined for metformin users and nonusers by modelling restricted cubic splines obtained from a Cox regression model. RESULTS Of 37,293 included patients, 3183 (9%) used metformin. The median (interquartile range) lactate level was 1.8 (1.2-3.2) in metformin users and 1.6 (1.0-2.7) mmol/L in metformin nonusers. Lactate levels were strongly associated with mortality for both metformin users and nonusers. However, the association of lactate with mortality was different for metformin users, with a lower mortality rate in metformin users than in nonusers when admitted with similar lactate levels. This was observed over the whole range of lactate levels, and consequently, the relation of lactate with mortality was shifted rightwards for metformin users. CONCLUSION In this large observational cohort of critically ill patients, early lactate levels were strongly associated with mortality. Irrespective of the degree of hyperlactataemia, similar lactate levels were associated with a lower mortality rate in metformin users compared with metformin nonusers. Therefore, lactate levels around ICU admission should be interpreted according to metformin use.
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Affiliation(s)
- Rene A Posma
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands. .,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Trine Frøslev
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
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Derkach KV, Romanova IV, Zorina II, Bakhtyukov AA, Perminova AA, Ivantsov AO, Shpakov AO. Effect of High-Dose Metformin on the Metabolic Parameters and Functional State of the Liver of Agouti Mice with Melanocortin Obesity. ADVANCES IN GERONTOLOGY 2020. [DOI: 10.1134/s2079057020010038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Taub ES, Hoffman RS, Manini AF. Incidence and risk factors for hyperlactatemia in ED patients with acute metformin overdose. Am J Emerg Med 2019; 37:2205-2208. [PMID: 30967322 PMCID: PMC9881186 DOI: 10.1016/j.ajem.2019.03.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/22/2019] [Accepted: 03/22/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The goals of this study are to describe clinical characteristics and risk factors for metabolic acidosis with hyperlactatemia in emergency department (ED) patients with acute metformin overdose. METHODS This was a secondary analysis of data from a retrospective observational cohort of adult ED patients presenting with acute drug overdose at two tertiary care hospitals over 5 years. The primary outcomes were: (1) hyperlactatemia, defined as a lactate concentration ≥ 2 mmol/L at any point during hospital admission and, (2) metformin associated lactic acidosis (MALA), defined as a lactate concentration ≥ 5 mmol/L and pH <7.35 at any point during hospital admission. RESULTS We screened 3739 acute overdoses; 2872 met eligibility, 56 self-reported metformin overdose (57% female, mean age 55.8). Of these, 39 had measured lactate values. There was a high incidence of hyperlactatemia (56.4%); MALA was less frequent (17.9%). There were no deaths. Low serum bicarbonate was an independent clinical risk factor for hyperlactatemia (adjusted p < 0.05). Acetaminophen co-exposure was an independent clinical risk factor for MALA (OR 24.40, 95% CI 1.6-376.4). CONCLUSIONS In ED patients with acute metformin overdose, initial hyperlactatemia is common but MALA is unusual. Acetaminophen co-exposure is a novel independent risk factor for the occurrence of MALA that deserves further investigation.
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Affiliation(s)
- Emily S Taub
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, New York, USA.
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, New York, USA.
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, NY, New York, USA.
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14
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Abstract
RATIONALE Metformin has been demonstrated to decrease infarct size (IS) and prevent postinfarction left ventricular (LV) remodeling in rodents when given intravenously at the time of reperfusion. It remains unclear whether similar cardioprotection can be achieved in a large animal model. OBJECTIVE The objective of this study was to determine whether intravascular infusion of metformin at the time of reperfusion reduces myocardial IS in a porcine model of acute myocardial infarction. METHODS AND RESULTS In a blinded and randomized preclinical study, closed-chest swine (n=20) were subjected to a 60-minute left anterior descending coronary artery occlusion to produce myocardial infarction. Contrast-enhanced computed tomography was performed during left anterior descending coronary artery occlusion to assess the ischemic area-at-risk. Animals were randomized to receive either metformin or vehicle as an initial intravenous bolus (5 mg/kg) 8 minutes before reperfusion, followed by a 15-minute left coronary artery infusion (1 mg/kg per minute) commencing with the onset of reperfusion. Echocardiography and computed tomographic imaging of LV function were performed 1 week later, at which time the heart was removed for postmortem pathological analysis of area-at-risk and IS (triphenyltetrazolium chloride). Baseline variables including hemodynamics and LV function were similar between groups. Peak circulating metformin concentrations of 374±35 µmol/L were achieved 15 minutes after reperfusion. There was no difference between the area-at-risk as a percent of LV mass by computed tomography (vehicle: 20.7%±1.1% versus metformin: 19.7%±1.3%; P=0.59) or postmortem pathology (22.4%±1.2% versus 20.2%±1.2%; P=0.21). IS relative to area-at-risk averaged 44.5%±5.0% in vehicle-treated versus 38.2%±6.8% in metformin-treated animals ( P=0.46). There was no difference in global function 7 days after myocardial infarction as assessed by echocardiography or computed tomographic ejection fraction (56.2%±2.6% versus 56.3%±2.4%; P=0.98). CONCLUSIONS In contrast to rodent hearts, postconditioning with high-dose metformin administered immediately before reperfusion does not reduce IS or improve LV function 7 days after myocardial infarction in swine. These results reinforce the importance of rigorously testing therapies in large animal models to facilitate clinical translation of novel cardioprotective therapies.
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Affiliation(s)
- George Techiryan
- From the VA WNY Health Care System and the Departments of Medicine, Pharmacology and Toxicology, Physiology and Biophysics, and Biomedical Engineering, and the Clinical and Translational Research Center of the University at Buffalo, NY
| | - Brian R Weil
- From the VA WNY Health Care System and the Departments of Medicine, Pharmacology and Toxicology, Physiology and Biophysics, and Biomedical Engineering, and the Clinical and Translational Research Center of the University at Buffalo, NY
| | - Beth A Palka
- From the VA WNY Health Care System and the Departments of Medicine, Pharmacology and Toxicology, Physiology and Biophysics, and Biomedical Engineering, and the Clinical and Translational Research Center of the University at Buffalo, NY
| | - John M Canty
- From the VA WNY Health Care System and the Departments of Medicine, Pharmacology and Toxicology, Physiology and Biophysics, and Biomedical Engineering, and the Clinical and Translational Research Center of the University at Buffalo, NY
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15
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Lee MC, Lee CH, Chang LY, Chang CH, Zhang JF, Lee MR, Wang JY, Chen SM. Association of Metformin Use With End-Stage Renal Disease in Patients With Type 2 Diabetes Mellitus: A Nationwide Cohort Study Under the Pay-for-Performance Program. J Clin Pharmacol 2019; 59:1443-1452. [PMID: 31163098 DOI: 10.1002/jcph.1452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/16/2019] [Indexed: 12/25/2022]
Abstract
Animal studies have demonstrated that metformin exerts a renoprotective effect. Human studies of patients with diabetes mellitus (DM) regarding the association of metformin use with end-stage renal disease (ESRD) are lacking. Patients with type 2 DM and without a history of kidney disease who were enrolled under the pay-for-performance program of the National Health Insurance in Taiwan were identified. Those who received ≥90 cumulative defined daily doses of metformin within 1 year were selected (metformin users) and compared with a 1:1 propensity score-matched metformin nonuser cohort. Primary and secondary outcomes were development of ESRD and chronic kidney disease (CKD), respectively. Independent predictors were investigated using Cox regression analysis. A total of 24 158 pairs of metformin users and nonusers were enrolled, with an incidence of ESRD of 1908 and 1723 and CKD of 1095 and 1056 cases per 100 000 person-years, respectively. Metformin use was independently associated with increased risks of ESRD (adjusted hazard ratio, 1.22; 95% confidence interval, 1.12-1.32) and CKD (adjusted hazard ratio, 1.25; 95% confidence interval, 1.12-1.40) in a dose-response relationship. Patients with hypertension plus nonuse of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers potentiated kidney damage by metformin. In patients with DM, use of metformin may increase the risk of ESRD and CKD. Health care professionals should be alert and closely monitor renal function when prescribing metformin.
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Affiliation(s)
- Ming-Chia Lee
- Department of Pharmacy, New Taipei City Hospital, New Taipei City, Taiwan.,School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Lih-Yu Chang
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chia-Hao Chang
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jun-Fu Zhang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Rui Lee
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Ming Chen
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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16
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Derkach K, Zakharova I, Zorina I, Bakhtyukov A, Romanova I, Bayunova L, Shpakov A. The evidence of metabolic-improving effect of metformin in Ay/a mice with genetically-induced melanocortin obesity and the contribution of hypothalamic mechanisms to this effect. PLoS One 2019; 14:e0213779. [PMID: 30870482 PMCID: PMC6417728 DOI: 10.1371/journal.pone.0213779] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/19/2019] [Indexed: 12/16/2022] Open
Abstract
In diet-induced obesity, metformin (MF) has weight-lowering effect and improves glucose homeostasis and insulin sensitivity. However, there is no information on the efficiency of MF and the mechanisms of its action in melanocortin-type obesity. We studied the effect of the 10-day treatment with MF at the doses of 200, 400 and 600 mg/kg/day on the food intake and the metabolic and hormonal parameters in female C57Bl/6J (genotype Ay/a) agouti-mice with melanocortin-type obesity, and the influence of MF on the hypothalamic signaling in obese animals at the most effective metabolic dose (600 mg/kg/day). MF treatment led to a decrease in food intake, the body and fat weights, the plasma levels of glucose, insulin and leptin, all increased in agouti-mice, to an improvement of the lipid profile and glucose sensitivity, and to a reduced fatty liver degeneration. In the hypothalamus of obese agouti-mice, the leptin and insulin content was reduced and the expression of the genes encoding leptin receptor (LepR), MC3- and MC4-melanocortin receptors and pro-opiomelanocortin (POMC), the precursor of anorexigenic melanocortin peptides, was increased. The activities of AMP-activated kinase (AMPK) and the transcriptional factor STAT3 were increased, while Akt-kinase activity did not change from control C57Bl/6J (a/a) mice. In the hypothalamus of MF-treated agouti-mice (10 days, 600 mg/kg/day), the leptin and insulin content was restored, Akt-kinase activity was increased, and the activities of AMPK and STAT3 were reduced and did not differ from control mice. In the hypothalamus of MF-treated agouti-mice, the Pomc gene expression was six times higher than in control, while the gene expression for orexigenic neuropeptide Y was decreased by 39%. Thus, we first showed that MF treatment leads to an improvement of metabolic parameters and a decrease of hyperleptinemia and hyperinsulinaemia in genetically-induced melanocortin obesity, and the specific changes in the hypothalamic signaling makes a significant contribution to this effect of MF.
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Affiliation(s)
- Kira Derkach
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
| | - Irina Zakharova
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
| | - Inna Zorina
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
| | - Andrey Bakhtyukov
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
| | - Irina Romanova
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
| | - Liubov Bayunova
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
| | - Alexander Shpakov
- Department of Molecular Endocrinology and Neurochemistry, Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, St. Petersburg, Russia
- * E-mail:
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17
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Protti A. Succinate and the shortcut to the cure of metformin-induced lactic acidosis. Intensive Care Med Exp 2018; 6:35. [PMID: 30251134 PMCID: PMC6153199 DOI: 10.1186/s40635-018-0202-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/14/2018] [Indexed: 01/09/2023] Open
Abstract
Inhibition of the respiratory chain complex I plays a key role in the pathogenesis of metformin-induced lactic acidosis. In a work recently published in this journal, a novel cell-permeable succinate prodrug (NV118) increased in vitro mitochondrial oxygen consumption coupled with energy production and decreased lactate production in intact human platelets intoxicated with metformin. This result was interpreted in light of a "bypass" strategy. NV118 entered platelets and released succinate in their cytoplasm; succinate in turn donated electrons to complex II and thus reactivated the flow of electrons to the distal part of the respiratory chain independent of complex I. Herein, I will (1) comment on these findings; (2) highlight the potential therapeutic application of succinate in other critical conditions accompanied by complex I inhibition, including sepsis, traumatic brain injury, and inherited neurological disorders; and (3) examine the most important issues that remain to be solved to transfer these observations to the bedside.
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Affiliation(s)
- Alessandro Protti
- Department of Anaesthesia and Intensive Care, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122, Milan, Italy.
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18
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Abstract
In the 1920s, guanidine, the active component of Galega officinalis, was shown to lower glucose levels and used to synthesize several antidiabetic compounds. Metformin (1,1 dimethylbiguanide) is the most well-known and currently the only marketed biguanide in the United States, United Kingdom, Canada, and Australia for the treatment of non-insulin-dependent diabetes mellitus. Although phenformin was removed from the US market in the 1970s, it is still available around the world and can be found in unregulated herbal supplements. Adverse events associated with therapeutic use of biguanides include gastrointestinal upset, vitamin B12 deficiency, and hemolytic anemia. Although the incidence is low, metformin toxicity can lead to hyperlactatemia and metabolic acidosis. Since metformin is predominantly eliminated from the body by the kidneys, toxicity can occur when metformin accumulates due to poor clearance from renal insufficiency or in the overdose setting. The dominant source of metabolic acidosis associated with hyperlactatemia in metformin toxicity is the rapid cytosolic adenosine triphosphate (ATP) turnover when complex I is inhibited and oxidative phosphorylation cannot adequately recycle the vast quantity of H+ from ATP hydrolysis. Although metabolic acidosis and hyperlactatemia are markers of metformin toxicity, the degree of hyperlactatemia and severity of acidemia have not been shown to be of prognostic value. Regardless of the etiology of toxicity, treatment should include supportive care and consideration for adjunct therapies such as gastrointestinal decontamination, glucose and insulin, alkalinization, extracorporeal techniques to reduce metformin body burden, and metabolic rescue.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Hospital, Aurora, CO, USA
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19
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Qi H, Nielsen PM, Schroeder M, Bertelsen LB, Palm F, Laustsen C. Acute renal metabolic effect of metformin assessed with hyperpolarised MRI in rats. Diabetologia 2018; 61:445-454. [PMID: 28936623 DOI: 10.1007/s00125-017-4445-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/04/2017] [Indexed: 01/07/2023]
Abstract
AIMS/HYPOTHESIS Metformin inhibits hepatic mitochondrial glycerol phosphate dehydrogenase, thereby increasing cytosolic lactate and suppressing gluconeogenesis flux in the liver. This inhibition alters cytosolic and mitochondrial reduction-oxidation (redox) potential, which has been reported to protect organ function in several disease states including diabetes. In this study, we investigated the acute metabolic and functional changes induced by metformin in the kidneys of both healthy and insulinopenic Wistar rats used as a model of diabetes. METHODS Diabetes was induced by intravenous injection of streptozotocin, and kidney metabolism in healthy and diabetic animals was investigated 4 weeks thereafter using hyperpolarised 13C-MRI, Clark-type electrodes and biochemical analysis. RESULTS Metformin increased renal blood flow, but did not change total kidney oxygen consumption. In healthy rat kidneys, metformin increased [1-13C]lactate production and reduced mitochondrial [1-13C]pyruvate oxidation (decreased the 13C-bicarbonate/[1-13C]pyruvate ratio) within 30 min of administration. Corresponding alterations to indices of mitochondrial, cytosolic and whole-cell redox potential were observed. Pyruvate oxidation was maintained in the diabetic rats, suggesting that the diabetic state abrogates metabolic reprogramming caused by metformin. CONCLUSIONS/INTERPRETATION This study demonstrates that metformin-induced acute metabolic alterations in healthy kidneys favoured anaerobic metabolism at the expense of aerobic metabolism. The results suggest that metformin directly alters the renal redox state, with elevated renal cytosolic redox states as well as decreased mitochondrial redox state. These findings suggest redox biology as a novel target to eliminate the renal complications associated with metformin treatment in individuals with impaired renal function.
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Affiliation(s)
- Haiyun Qi
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Per M Nielsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marie Schroeder
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Lotte B Bertelsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Fredrik Palm
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Christoffer Laustsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
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20
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Jochmans S, Alphonsine JE, Chelly J, Vong LVP, Sy O, Rolin N, Ellrodt O, Monchi M, Vinsonneau C. Does metformin exposure before ICU stay have any impact on patients' outcome? A retrospective cohort study of diabetic patients. Ann Intensive Care 2017; 7:116. [PMID: 29198069 PMCID: PMC5712297 DOI: 10.1186/s13613-017-0336-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 11/04/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Impact of metformin exposure before ICU stay remains controversial. Metformin is thought to induce lactic acidosis and haemodynamic instability but may reduce ICU mortality. We evaluated its influence on outcome in diabetic patients admitted in the ICU and then compared two different populations based on the presence of septic shock. METHODS We conducted a retrospective cohort study in a 24-bed French ICU between October 2010 and December 2013, including all ICU-admitted diabetic patients. RESULTS Among 635 diabetic patients admitted during the study period, 131 (21%) were admitted with septic shock. Multivariate analysis showed no difference in hospital mortality in all metformin users (OR 0.75 [95% CI 0.44-1.28]; p = 0.29), except in the septic shock subgroup (OR 0.61; 95% CI [0.37-0.99]; p = 0.04) despite higher vasopressor dosages in the first hours after shock onset. Blood lactate level was higher in metformin users than in non-metformin users in all patients (p < 0.001), in septic shock patients (p < 0.001) and in patients without kidney injury (p < 0.001). Metformin users did not have more septic shock from unknown aetiology (p = 0.65) or unknown pathogen (p = 0.99). CONCLUSIONS Metformin use before admission to ICU did not affect in-hospital mortality. However, for patients with septic shock, mortality was lower, despite worse clinical presentation on admission. Blood lactate levels were always higher with or without septic shock and indifferent of kidney function.
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Affiliation(s)
- Sebastien Jochmans
- Département de Médecine Intensive et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | | | - Jonathan Chelly
- Département de Médecine Intensive et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Ly Van Phach Vong
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Oumar Sy
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Nathalie Rolin
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Olivier Ellrodt
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Mehran Monchi
- Département de Médecine Intensive et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
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21
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Barrella N, Eisenberg B, Simpson SN. Hypoglycemia and severe lactic acidosis in a dog following metformin exposure. Clin Case Rep 2017; 5:2097-2104. [PMID: 29225865 PMCID: PMC5715605 DOI: 10.1002/ccr3.1255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/01/2017] [Accepted: 10/06/2017] [Indexed: 01/18/2023] Open
Abstract
Hypoglycemia and lactic acidosis are rare complications with metformin use in humans. As metformin is not commonly used in veterinary medicine, severe adverse effects secondary to exposure are not known. Awareness of potentially life-threatening complications with metformin exposure is an important addition to the veterinary literature.
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Affiliation(s)
- Nicole Barrella
- Massachusetts Veterinary Referral HospitalWoburnMassachusetts01801USA
- Present address:
Bulger Veterinary HospitalNorth AndoverMassachusetts01845USA
| | - Beth Eisenberg
- Massachusetts Veterinary Referral HospitalWoburnMassachusetts01801USA
| | - Stephanie Nicole Simpson
- Massachusetts Veterinary Referral HospitalWoburnMassachusetts01801USA
- Present address:
VCA Roberts Animal HospitalHanoverMassachusetts02339USA
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22
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Chien LN, Chou CL, Chen HH, Kao CC, Lin YC, Wu YL, Chen JS, Chen LY, Fang TC. Association Between Stroke Risk and Metformin Use in Hemodialysis Patients With Diabetes Mellitus: A Nested Case-Control Study. J Am Heart Assoc 2017; 6:JAHA.117.007611. [PMID: 29146610 PMCID: PMC5721805 DOI: 10.1161/jaha.117.007611] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Metformin use reduces the incidence and severity of stroke in patients with type 2 diabetes mellitus (DM). The benefits of metformin for stroke have not been examined in hemodialysis patients with DM. METHODS AND RESULTS Using the National Health Insurance Research Database, we identified 17 760 patients with DM and new-onset hemodialysis between 2001 and 2013. Of these, 1898 patients hospitalized for either ischemic or hemorrhagic stroke were matched to 7592 control patients according to sex, age, and year of initial hemodialysis therapy by using incidence sampling. The association between metformin use and stroke risk was estimated using conditional logistic regression after adjustment for hemodialysis frequency, comorbidity, and prescribed medications. Metformin use was recorded before the date of stroke admission and the date of pseudostroke of the case and control patients, respectively. Results showed that hemodialysis patients with ischemic stroke were more likely to use metformin than the controls 1 year before the date of stroke admission (adjusted odds ratio: 1.64; 95% confidence interval, 1.32-2.04). The association was evident within 90 days before the index date (adjusted odds ratio: 1.81; 95% confidence interval, 1.27-2.60). The results were consistent with those of hemodialysis patients with hemorrhagic stroke. Metformin use remained a risk factor for stroke in patients treated with antihypertensive, sulfonylurea, and antiplatelet drugs. CONCLUSIONS This nested case-control study is the first to show that metformin use is associated with stroke risk in hemodialysis patients with DM. We suggest that metformin should not be used by hemodialysis patients with DM.
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Affiliation(s)
- Li-Nien Chien
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Chu-Lin Chou
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - His-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yen-Chung Lin
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yueh-Lin Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jin-Shuen Chen
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Li-Ying Chen
- Health and Clinical Data Research Center, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Te-Chao Fang
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan .,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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23
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Lalau JD, Kajbaf F, Protti A, Christensen MM, De Broe ME, Wiernsperger N. Metformin-associated lactic acidosis (MALA): Moving towards a new paradigm. Diabetes Obes Metab 2017; 19:1502-1512. [PMID: 28417525 DOI: 10.1111/dom.12974] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/03/2017] [Accepted: 04/11/2017] [Indexed: 12/15/2022]
Abstract
Although metformin has been used for over 60 years, the balance between the drug's beneficial and adverse effects is still subject to debate. Following an analysis of how cases of so-called "metformin-associated lactic acidosis" (MALA) are reported in the literature, the present article reviews the pitfalls to be avoided when assessing the purported association between metformin and lactic acidosis. By starting from pathophysiological considerations, we propose a new paradigm for lactic acidosis in metformin-treated patients. Metformin therapy does not necessarily induce metformin accumulation, just as metformin accumulation does not necessarily induce hyperlactatemia, and hyperlactatemia does not necessarily induce lactic acidosis. In contrast to the conventional view, MALA probably accounts for a smaller proportion of cases than either metformin-unrelated lactic acidosis or metformin-induced lactic acidosis. Lastly, this review highlights the need for substantial improvements in the reporting of cases of lactic acidosis in metformin-treated patients. Accordingly, we propose a check-list as a guide to clinical practice.
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Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, Amiens University Hospital, Amiens, France
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, Amiens University Hospital, Amiens, France
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care, IRCCS Fondazione Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Mette M Christensen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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24
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Bell S, Farran B, McGurnaghan S, McCrimmon RJ, Leese GP, Petrie JR, McKeigue P, Sattar N, Wild S, McKnight J, Lindsay R, Colhoun HM, Looker H. Risk of acute kidney injury and survival in patients treated with Metformin: an observational cohort study. BMC Nephrol 2017; 18:163. [PMID: 28526011 PMCID: PMC5437411 DOI: 10.1186/s12882-017-0579-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Whether metformin precipitates lactic acidosis in patients with chronic kidney disease (CKD) remains under debate. We examined whether metformin use was associated with an increased risk of acute kidney injury (AKI) as a proxy for lactic acidosis and whether survival among those with AKI varied by metformin exposure. METHODS All individuals with type 2 diabetes and available prescribing data between 2004 and 2013 in Tayside, Scotland were included. The electronic health record for diabetes which includes issued prescriptions was linked to laboratory biochemistry, hospital admission, death register and Scottish Renal Registry data. AKI events were defined using the Kidney Disease Improving Global Outcomes criteria with a rise in serum creatinine of at least 26.5 μmol/l or a rise of greater than 150% from baseline for all hospital admissions. Cox Regression Analyses were used to examine whether person-time periods in which current metformin exposure occurred were associated with an increased rate of first AKI compared to unexposed periods. Cox regression was also used to compare 28 day survival rates following first AKI events in those exposed to metformin versus those not exposed. RESULTS Twenty-five thousand one-hundred fourty-eight patients were included with a total person-time of 126,904 person years. 4944 (19.7%) people had at least one episode of AKI during the study period. There were 32.4 cases of first AKI/1000pyrs in current metformin exposed person-time periods compared to 44.9 cases/1000pyrs in unexposed periods. After adjustment for age, sex, diabetes duration, calendar time, number of diabetes drugs and baseline renal function, current metformin use was not associated with AKI incidence, HR 0.94 (95% CI 0.87, 1.02, p = 0.15). Among those with incident AKI, being on metformin at admission was associated with a higher rate of survival at 28 days (HR 0.81, 95% CI 0.69, 0.94, p = 0.006) even after adjustment for age, sex, pre-admission eGFR, HbA1c and diabetes duration. CONCLUSIONS Contrary to common perceptions, we found no evidence that metformin increases incidence of AKI and was associated with higher 28 day survival following incident AKI.
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Affiliation(s)
- Samira Bell
- Renal Unit, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Bassam Farran
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Rory J McCrimmon
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Graham P Leese
- Department of Medicine, University of Dundee, Dundee, UK
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul McKeigue
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Sarah Wild
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
| | - John McKnight
- Department of Medicine, Western General Hospital, Edinburgh, UK
| | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Helen Looker
- Division of Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
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Carlson N, Hommel K, Olesen JB, Gerds TA, Soja AM, Vilsbøll T, Kamper AL, Torp-Pedersen C, Gislason G. Metformin-associated risk of acute dialysis in patients with type 2 diabetes: A nationwide cohort study. Diabetes Obes Metab 2016; 18:1283-1287. [PMID: 27534835 DOI: 10.1111/dom.12764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 11/28/2022]
Abstract
Recent guidelines governing anti-diabetic medications increasingly advocate metformin as first-line therapy in all patients with type 2 diabetes. However, metformin could be associated with increased risk of acute kidney injury (AKI), acute dialysis and lactate acidosis in marginal patients. In a retrospective nationwide cohort study, a total of 168 443 drug-naïve patients with type 2 diabetes ≥50 years, initiating treatment with either metformin or sulphonyl in Denmark between 2000 and 2012 were included in this study (70.7% initiated treatment with metformin); calculation of 1-year risk of acute dialysis was based on g-standardization of cause-specific Cox regression models for acute dialysis, end-stage renal disease and death. One-year risks of acute dialysis were 92.4 per 100 000 (95% CI, 67.1-121.3) and 142.7 per 100 000 (95% CI, 118.3-168.0) for sulphonylurea and metformin, respectively. The metformin-associated 1-year risk of acute dialysis was increased by 50.3 per 100 000 (95% CI, 7.9-88.6), corresponding to a risk ratio of 1.53 (95% CI, 1.06-2.23), and a number needed to harm of 1988, thus providing evidence of potential concerns pertaining to the increasing use of metformin.
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Affiliation(s)
- Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
- Department of Nephrology, Herlev Hospital, Copenhagen University, Herlev, Denmark
| | - Kristine Hommel
- Department of Nephrology, Herlev Hospital, Copenhagen University, Herlev, Denmark
| | - Jonas B Olesen
- Department of Cardiology, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
| | - Thomas A Gerds
- Department of Biostatistics, Copenhagen University, Copenhagen, Denmark
| | - Anne-Merete Soja
- Department of Cardiology, Hvidovre Hospital, Copenhagen University, Hvidovre, Denmark
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | | | - Gunnar Gislason
- Department of Cardiology, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
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Karlsson M, Ehinger JK, Piel S, Sjövall F, Henriksnäs J, Höglund U, Hansson MJ, Elmér E. Changes in energy metabolism due to acute rotenone-induced mitochondrial complex I dysfunction – An in vivo large animal model. Mitochondrion 2016; 31:56-62. [DOI: 10.1016/j.mito.2016.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 10/06/2016] [Accepted: 10/13/2016] [Indexed: 12/30/2022]
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Cucchiari D, Podestà MA, Merizzoli E, Calvetta A, Morenghi E, Angelini C, Ponticelli C, Badalamenti S. Dose-related effects of metformin on acid-base balance and renal function in patients with diabetes who develop acute renal failure: a cross-sectional study. Acta Diabetol 2016; 53:551-8. [PMID: 26821225 DOI: 10.1007/s00592-016-0836-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 01/01/2016] [Indexed: 12/21/2022]
Abstract
AIMS The role of metformin in the development of lactic acidosis (LA) in the setting of acute renal failure (ARF) is debated. Moreover, recent experiments suggested that metformin can also be nephrotoxic, but little clinical data exist about this topic. We sought to investigate these possible associations in a large cohort of patients with diabetes who developed ARF. METHODS We analyzed data from patients with diabetes admitted to our emergency department between 2007 and 2011 with ARF and a previously normal renal function (n = 126). We compared acid-base balance and renal function of patients taking metformin (n = 74) with patients not taking it (n = 52). RESULTS Patients taking metformin had decreased pH (7.31 ± 0.16 vs 7.39 ± 0.11, p = 0.008) and higher lactates (4.54 ± 4.30 vs 1.71 ± 1.14 mmol/L, p < 0.001). Both acidosis (pH < 7.35) and LA (lactates >5 mmol/L and pH < 7.35) were more frequently observed in this group (p = 0.0491 and p < 0.001, respectively). Multivariate analysis ruled out the role of some possible confounders, especially decreased renal function. The influence of metformin on pH and lactates grew significantly with higher doses of the drug (p = 0.259 and p = 0.092 for <1 g/day, p = 0.289 and p < 0.001 for 1-2 g/day, p = 0.009 and p < 0.001 for 2-3 g/day, for pH and lactates, respectively). Metformin influenced creatinine levels in a dose-related manner as well (p = 0.925 for <1 g/day, p = 0.033 for 1-2 g/day, p < 0.001 for 2-3 g/day). CONCLUSIONS In patients with diabetes who were admitted to our emergency department with ARF, the use of metformin was associated in a dose-related fashion with both LA and worse renal function.
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Affiliation(s)
- David Cucchiari
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy.
| | - Manuel Alfredo Podestà
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Elisa Merizzoli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Albania Calvetta
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Emanuela Morenghi
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Claudio Angelini
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Claudio Ponticelli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Salvatore Badalamenti
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
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Changes in Whole-Body Oxygen Consumption and Skeletal Muscle Mitochondria During Linezolid-Induced Lactic Acidosis. Crit Care Med 2016; 44:e579-82. [DOI: 10.1097/ccm.0000000000001478] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Protti A, Properzi P, Magnoni S, Santini A, Langer T, Guenzani S, Ferrero S, Bassani G, Stocchetti N, Gattinoni L. Skeletal muscle lactate overproduction during metformin intoxication: An animal study with reverse microdialysis. Toxicol Lett 2016; 255:43-6. [PMID: 27178268 DOI: 10.1016/j.toxlet.2016.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/02/2016] [Accepted: 05/09/2016] [Indexed: 12/24/2022]
Abstract
Lactic acidosis during metformin intoxication is classically mainly attributed to diminished lactate clearance through liver gluconeogenesis. Here we studied 6 healthy, sedated and mechanically ventilated pigs to clarify whether high dose of metformin also increases skeletal muscle lactate production. Each animal had two microdialysis catheters inserted in gluteus muscles, one per side. One catheter was infused with saline (control) while the other one was infused with metformin diluted in saline (1M), both at a rate of 0.3μl/min. Dialysate lactate concentration and lactate-to-pyruvate ratio, a marker of the balance between anaerobic glycolysis and aerobic (mitochondrial) metabolism, were measured every 3h, for 12h. Continuous infusion of metformin caused a progressive rise in dialysate lactate level (p=0.007) and lactate-to-pyruvate ratio (p<0.001) compared to that of saline, as for mitochondrial "poisoning". These findings suggest that skeletal muscle lactate overproduction contributes to the development of metformin-induced lactic acidosis.
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Affiliation(s)
- Alessandro Protti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
| | - Paolo Properzi
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Sandra Magnoni
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Santini
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Thomas Langer
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Guenzani
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi, Milan, Italy
| | - Stefano Ferrero
- U.O.C. Anatomia Patologica, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi, Milan, Italy
| | - Giulia Bassani
- Centro di Ricerche Chirurgiche Precliniche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | - Nino Stocchetti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi, Milan, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi, Milan, Italy
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Doenyas-Barak K, Beberashvili I, Marcus R, Efrati S. Lactic acidosis and severe septic shock in metformin users: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:10. [PMID: 26775158 PMCID: PMC4715304 DOI: 10.1186/s13054-015-1180-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 12/29/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND High serum lactate is associated with increased mortality in septic shock patients. Metformin alters lactate metabolism, and may affect its prognostic value. We compared, between metformin users and nonusers, the prognosis of extremely elevated plasma lactate levels in patients with septic shock. METHODS The electronic medical records (EMR) of patients admitted to the emergency room between January 2011 and June 2013 were reviewed. The study cohort comprised patients with an initial diagnosis of septic shock and blood lactate higher than 10 mmol/L. The selected population was divided into two groups: metformin users (exposed) and metformin nonusers (unexposed). The primary outcome measured was inhospital mortality. RESULTS The study included 44 metformin users and 118 nonusers. Metformin users were similar to nonusers with respect to levels of lactate, HCO3, and blood pH; however, they were older and had higher incidence rates of cardiovascular disease and acute kidney injury at admission, compared to nonusers. Inhospital mortality rates were significantly lower in the metformin-treated group, 56.8 % vs. 88.1 %, p <0.0001. CONCLUSIONS Though high lactate concentration indicates poor prognosis in septic patients, mortality rate was found to be significantly lower in those who were treated with metformin. This finding may help clinicians in deciding treatment for these patients, who could otherwise be considered too ill for real treatment benefit.
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Affiliation(s)
- Keren Doenyas-Barak
- Department of Nephrology, Assaf Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Zerifin, 70300, Israel. .,Research and Development Unit, Assaf Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Zerifin, 70300, Israel.
| | - Ilia Beberashvili
- Department of Nephrology, Assaf Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Zerifin, 70300, Israel
| | - Ronit Marcus
- Internal Medicine C Department, Assaf Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Zerifin, 70300, Israel
| | - Shai Efrati
- Department of Nephrology, Assaf Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Zerifin, 70300, Israel.,Research and Development Unit, Assaf Harofeh Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Zerifin, 70300, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, 69978, Israel
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Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med 2015; 43:1716-30. [PMID: 25860205 DOI: 10.1097/ccm.0000000000001002] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Metformin toxicity, a challenging clinical entity, is associated with a mortality of 30%. The role of extracorporeal treatments such as hemodialysis is poorly defined at present. Here, the Extracorporeal Treatments In Poisoning workgroup, comprising international experts representing diverse professions, presents its systematic review and clinical recommendations for extracorporeal treatment in metformin poisoning. METHODS A systematic literature search was performed, data extracted, findings summarized, and structured voting statements developed. A two-round modified Delphi method was used to achieve consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Anonymized votes and opinions were compiled and discussed. A second vote determined the final recommendations. RESULTS One hundred seventy-five articles were identified, including 63 deaths: one observational study, 160 case reports or series, 11 studies of descriptive cohorts, and three pharmacokinetic studies in end-stage renal disease, yielding a very low quality of evidence for all recommendations. The workgroup concluded that metformin is moderately dialyzable (level of evidence C) and made the following recommendations: extracorporeal treatment is recommended in severe metformin poisoning (1D). Indications for extracorporeal treatment include lactate concentration greater than 20 mmol/L (1D), pH less than or equal to 7.0 (1D), shock (1D), failure of standard supportive measures (1D), and decreased level of consciousness (2D). Extracorporeal treatment should be continued until the lactate concentration is less than 3 mmol/L (1D) and pH greater than 7.35 (1D), at which time close monitoring is warranted to determine the need for additional courses of extracorporeal treatment. Intermittent hemodialysis is preferred initially (1D), but continuous renal replacement therapies may be considered if hemodialysis is unavailable (2D). Repeat extracorporeal treatment sessions may use hemodialysis (1D) or continuous renal replacement therapy (1D). CONCLUSION Metformin poisoning with lactic acidosis appears to be amenable to extracorporeal treatments. Despite clinical evidence comprised mostly of case reports and suboptimal toxicokinetic data, the workgroup recommended extracorporeal removal in the case of severe metformin poisoning.
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Kajbaf F, De Broe ME, Lalau JD. Therapeutic Concentrations of Metformin: A Systematic Review. Clin Pharmacokinet 2015; 55:439-59. [DOI: 10.1007/s40262-015-0323-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Hung SC, Chang YK, Liu JS, Kuo KL, Chen YH, Hsu CC, Tarng DC. Metformin use and mortality in patients with advanced chronic kidney disease: national, retrospective, observational, cohort study. Lancet Diabetes Endocrinol 2015; 3:605-14. [PMID: 26094107 DOI: 10.1016/s2213-8587(15)00123-0] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Metformin is recommended as a first-line treatment for patients with type 2 diabetes. However, use of this drug has been contraindicated in individuals with impaired kidney function because of the perceived risk of lactic acidosis. Evidence now supports cautious use of metformin in people with mild-to-moderate chronic kidney disease. However, studies examining the use of metformin in patients with advanced chronic kidney disease are lacking. We aimed to assess the safety of metformin in patients with type 2 diabetes and advanced (approximately stage 5) chronic kidney disease. METHODS We did a retrospective, observational, cohort study of patients with type 2 diabetes who were enrolled prospectively in Taiwan's national health insurance research database between Jan 1, 2000, and June 30, 2009, and had follow-up data until Dec 31, 2009. We included individuals with a serum creatinine concentration greater than 530 μmol/L, which is approximately equivalent to stage 5 chronic kidney disease. From a consecutive sample of 12 350 patients with type 2 diabetes and chronic kidney disease, 1005 used metformin and 11 345 were non-users. We matched users and non-users of metformin by propensity score in a 1:3 ratio. Our primary outcome was all-cause mortality. FINDINGS 813 metformin users were matched by propensity score to 2439 non-users. The two groups of patients did not differ significantly by 30 baseline clinical and socioeconomic variables. Median follow-up in the matched cohort was 2·1 years (range 0·3-9·8). All-cause mortality was reported in 434 (53%) of 813 metformin users and in 1012 (41%) of 2439 non-users. After multivariate adjustment, metformin use was an independent risk factor for mortality (adjusted hazard ratio 1·35, 95% CI 1·20-1·51; p<0·0001). The increased mortality risk was dose-dependent and was consistent across all subgroup analyses. However, metformin use compared with no use was associated with a higher but non-significant risk of metabolic acidosis (1·6 vs 1·3 events per 100 patient-years; adjusted hazard ratio 1·30, 95% CI 0·88-1·93; p=0·19). INTERPRETATION Use of metformin in people with type 2 diabetes and a serum creatinine concentration greater than 530 μmol/L is associated with a significantly increased risk of all-cause mortality compared with non-users. Metformin use should not be encouraged in this patient group. FUNDING Taipei Tzu Chi Hospital, Taipei Veterans General Hospital, Foundation for Poison Control, National Health Research Institutes, Ministry of Science and Technology of Taiwan.
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Affiliation(s)
- Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Kang Chang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Jia-Sin Liu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Hsin Chen
- Division of Nephrology, Department of Internal Medicine, Taipei City Hospital Yang-Ming Branch, Taipei, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan; Department of Health Services Administration, China Medical University, Taichung, Taiwan.
| | - Der-Cherng Tarng
- Institutes of Physiology and Clinical Medicine, National Yang-Ming University, and Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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McNamara K, Isbister GK. Hyperlactataemia and clinical severity of acute metformin overdose. Intern Med J 2015; 45:402-8. [DOI: 10.1111/imj.12713] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/02/2015] [Indexed: 11/29/2022]
Affiliation(s)
- K. McNamara
- Department of Clinical Toxicology and Pharmacology; Calvary Mater Newcastle; Newcastle New South Wales Australia
| | - G. K. Isbister
- Department of Clinical Toxicology and Pharmacology; Calvary Mater Newcastle; Newcastle New South Wales Australia
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
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Protti A, Fortunato F, Artoni A, Lecchi A, Motta G, Mistraletti G, Novembrino C, Comi GP, Gattinoni L. Platelet mitochondrial dysfunction in critically ill patients: comparison between sepsis and cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:39. [PMID: 25757508 PMCID: PMC4338849 DOI: 10.1186/s13054-015-0762-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 01/21/2015] [Indexed: 12/26/2022]
Abstract
Introduction Platelet mitochondrial respiratory chain enzymes (that produce energy) are variably inhibited during human sepsis. Whether these changes occur even during other acute critical illness or are associated with impaired platelet aggregation and secretion (that consume energy) is not known. The aims of this study were firstly to compare platelet mitochondrial respiratory chain enzymes activity between patients with sepsis and those with cardiogenic shock, and secondly to study the relationship between platelet mitochondrial respiratory chain enzymes activity and platelet responsiveness to (exogenous) agonists in patients with sepsis. Methods This was a prospective, observational, case–control study. Platelets were isolated from venous blood of 16 patients with severe sepsis or septic shock (free from antiplatelet drugs) and 16 others with cardiogenic shock, within 48 hours from admission to Intensive Care. Platelet mitochondrial respiratory chain enzymes activity was measured with spectrophotometry and expressed relative to citrate synthase activity, a marker of mitochondrial density. Platelet aggregation and secretion in response to adenosine di-phosphate (ADP), collagen, U46619 and thrombin receptor activating peptide were measured with lumiaggregometry only in patients with sepsis. In total, 16 healthy volunteers acted as controls for both spectrophotometry and lumiaggregometry. Results Platelets of patients with sepsis or cardiogenic shock similarly had lower mitochondrial nicotinamide adenine dinucleotide dehydrogenase (NADH) (P < 0.001), complex I (P = 0.006), complex I and III (P < 0.001) and complex IV (P < 0.001) activity than those of controls. Platelets of patients with sepsis were generally hypo-responsive to exogenous agonists, both in terms of maximal aggregation (P < 0.001) and secretion (P < 0.05). Lower mitochondrial NADH (R2 0.36; P < 0.001), complex I (R2 0.38; P < 0.001), complex I and III (R2 0.27; P = 0.002) and complex IV (R2 0.43; P < 0.001) activity was associated with lower first wave of aggregation with ADP. Conclusions Several platelet mitochondrial respiratory chain enzymes are similarly inhibited during human sepsis and cardiogenic shock. In patients with sepsis, mitochondrial dysfunction is associated with general platelet hypo-responsiveness to exogenous agonists. Trial registration ClinicalTrials.gov NCT00541827. Registered 8 October 2007.
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Affiliation(s)
- Alessandro Protti
- U.O. Terapia Intensiva 'Emma Vecla', Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Francesco Fortunato
- U.O. Neurologia - Centro Dino Ferrari, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Andrea Artoni
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Anna Lecchi
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Giovanna Motta
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Giovanni Mistraletti
- U.O. Anestesia e Rianimazione, A.O. San Paolo, Università degli Studi di Milano, via A. Di Rudinì 8, 20100, Milan, Italy.
| | - Cristina Novembrino
- Laboratorio Centrale di Analisi Chimico Cliniche e Microbiologia, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Giacomo Pietro Comi
- U.O. Neurologia - Centro Dino Ferrari, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
| | - Luciano Gattinoni
- U.O. Terapia Intensiva 'Emma Vecla', Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F.sco Sforza 35, 20100, Milan, Italy.
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Piel S, Ehinger JK, Elmér E, Hansson MJ. Metformin induces lactate production in peripheral blood mononuclear cells and platelets through specific mitochondrial complex I inhibition. Acta Physiol (Oxf) 2015; 213:171-80. [PMID: 24801139 DOI: 10.1111/apha.12311] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 11/21/2013] [Accepted: 04/26/2014] [Indexed: 12/25/2022]
Abstract
AIM Metformin is a widely used antidiabetic drug associated with the rare side effect of lactic acidosis which has been proposed to be linked to drug-induced mitochondrial dysfunction. Using respirometry, the aim of this study was to evaluate mitochondrial toxicity of metformin to human blood cells in relation to that of phenformin, a biguanide analogue withdrawn in most countries due to a high incidence of lactic acidosis. METHODS Peripheral blood mononuclear cells and platelets were isolated from healthy volunteers, and integrated mitochondrial function was studied in permeabilized and intact cells using high-resolution respirometry. A wide concentration range of metformin (0.1-100 mm) and phenformin (25-500 μm) was investigated for dose- and time-dependent effects on respiratory capacities, lactate production and pH. RESULTS Metformin induced respiratory inhibition at complex I in peripheral blood mononuclear cells and platelets (IC50 0.45 mm and 1.2 mm respectively). Phenformin was about 20-fold more potent in complex I inhibition of platelets than metformin. Metformin further demonstrated a dose- and time-dependent respiratory inhibition and augmented lactate release at a concentration of 1 mm and higher. CONCLUSION Respirometry of human peripheral blood cells readily detected respiratory inhibition by metformin and phenformin specific to complex I, providing a suitable model for probing drug toxicity. Lactate production was increased at concentrations relevant for clinical metformin intoxication, indicating mitochondrial inhibition as a direct causative pathophysiological mechanism. Relative to clinical dosing, phenformin displayed a more potent respiratory inhibition than metformin, possibly explaining the higher incidence of lactic acidosis in phenformin-treated patients.
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Affiliation(s)
- S. Piel
- Mitochondrial Medicine; Department of Clinical Sciences; Lund University; Lund Sweden
- NeuroVive Pharmaceutical AB; Lund Sweden
| | - J. K. Ehinger
- Mitochondrial Medicine; Department of Clinical Sciences; Lund University; Lund Sweden
- NeuroVive Pharmaceutical AB; Lund Sweden
- Department of Otorhinolaryngology; Head and Neck Surgery; Skåne University Hospital; Lund Sweden
| | - E. Elmér
- Mitochondrial Medicine; Department of Clinical Sciences; Lund University; Lund Sweden
- NeuroVive Pharmaceutical AB; Lund Sweden
- Department of Clinical Neurophysiology; Skåne University Hospital & Lund University; Lund Sweden
| | - M. J. Hansson
- Mitochondrial Medicine; Department of Clinical Sciences; Lund University; Lund Sweden
- NeuroVive Pharmaceutical AB; Lund Sweden
- Department of Clinical Physiology; Skåne University Hospital & Lund University; Lund Sweden
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Vogt JA, Wachter U, Wagner K, Calzia E, Gröger M, Weber S, Stahl B, Georgieff M, Asfar P, Fontaine E, Radermacher P, Leverve XM, Wagner F. Effects of glycemic control on glucose utilization and mitochondrial respiration during resuscitated murine septic shock. Intensive Care Med Exp 2014; 2:19. [PMID: 26266919 PMCID: PMC4678133 DOI: 10.1186/2197-425x-2-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/08/2014] [Indexed: 12/13/2022] Open
Abstract
Background This study aims to test the hypothesis whether lowering glycemia improves mitochondrial function and thereby attenuates apoptotic cell death during resuscitated murine septic shock. Methods Immediately and 6 h after cecal ligation and puncture (CLP), mice randomly received either vehicle or the anti-diabetic drug EMD008 (100 μg · g-1). At 15 h post CLP, mice were anesthetized, mechanically ventilated, instrumented and rendered normo- or hyperglycemic (target glycemia 100 ± 20 and 180 ± 50 mg · dL-1, respectively) by infusing stable, non-radioactive isotope-labeled 13C6-glucose. Target hemodynamics was achieved by colloid fluid resuscitation and continuous i.v. noradrenaline, and mechanical ventilation was titrated according to blood gases and pulmonary compliance measurements. Gluconeogenesis and glucose oxidation were derived from blood and expiratory glucose and 13CO2 isotope enrichments, respectively; mathematical modeling allowed analyzing isotope data for glucose uptake as a function of glycemia. Postmortem liver tissue was analyzed for HO-1, AMPK, caspase-3, and Bax (western blotting) expression as well as for mitochondrial respiratory activity (high-resolution respirometry). Results Hyperglycemia lowered mitochondrial respiratory capacity; EMD008 treatment was associated with increased mitochondrial respiration. Hyperglycemia decreased AMPK phosphorylation, and EMD008 attenuated both this effect as well as the expression of activated caspase-3 and Bax. During hyperglycemia EMD008 increased HO-1 expression. During hyperglycemia, maximal mitochondrial oxidative phosphorylation rate was directly related to HO-1 expression, while it was unrelated to AMPK activation. According to the mathematical modeling, EMD008 increased the slope of glucose uptake plotted as a function of glycemia. Conclusions During resuscitated, polymicrobial, murine septic shock, glycemic control either by reducing glucose infusion rates or EMD008 improved glucose uptake and thereby liver tissue mitochondrial respiratory activity. EMD008 effects were more pronounced during hyperglycemia and coincided with attenuated markers of apoptosis. The effects of glucose control were at least in part due to the up-regulation of HO-1 and activation of AMPK. Electronic supplementary material The online version of this article (doi:10.1186/2197-425X-2-19) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Josef A Vogt
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Klinik für Anästhesiologie, Universitätsklinikum, Helmhotzstrasse 8-1, Ulm, 89081, Germany,
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Mitochondrial changes in platelets are not related to those in skeletal muscle during human septic shock. PLoS One 2014; 9:e96205. [PMID: 24787741 PMCID: PMC4006866 DOI: 10.1371/journal.pone.0096205] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/04/2014] [Indexed: 12/22/2022] Open
Abstract
Platelets can serve as general markers of mitochondrial (dys)function during several human diseases. Whether this holds true even during sepsis is unknown. Using spectrophotometry, we measured mitochondrial respiratory chain biochemistry in platelets and triceps brachii muscle of thirty patients with septic shock (within 24 hours from admission to Intensive Care) and ten surgical controls (during surgery). Results were expressed relative to citrate synthase (CS) activity, a marker of mitochondrial density. Patients with septic shock had lower nicotinamide adenine dinucleotide dehydrogenase (NADH)/CS (p = 0.015), complex I/CS (p = 0.018), complex I and III/CS (p<0.001) and complex IV/CS (p = 0.012) activities in platelets but higher complex I/CS activity (p = 0.021) in triceps brachii muscle than controls. Overall, NADH/CS (r2 = 0.00; p = 0.683) complex I/CS (r2 = 0.05; p = 0.173), complex I and III/CS (r2 = 0.01; p = 0.485), succinate dehydrogenase (SDH)/CS (r2 = 0.00; p = 0.884), complex II and III/CS (r2 = 0.00; p = 0.927) and complex IV/CS (r2 = 0.00; p = 0.906) activities in platelets were not associated with those in triceps brachii muscle. In conclusion, several respiratory chain enzymes were variably inhibited in platelets, but not in triceps brachii muscle, of patients with septic shock. Sepsis-induced mitochondrial changes in platelets do not reflect those in other organs.
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Lalau JD, Arnouts P, Sharif A, De Broe ME. Metformin and other antidiabetic agents in renal failure patients. Kidney Int 2014; 87:308-22. [PMID: 24599253 DOI: 10.1038/ki.2014.19] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/21/2013] [Accepted: 12/12/2013] [Indexed: 12/11/2022]
Abstract
This review mainly focuses on metformin, and considers oral antidiabetic therapy in kidney transplant patients and the potential benefits and risks of antidiabetic agents other than metformin in patients with chronic kidney disease (CKD). In view of the debate concerning lactic acidosis associated with metformin, this review tries to solve a paradox: metformin should be prescribed more widely because of its beneficial effects, but also less widely because of the increasing prevalence of contraindications to metformin, such as reduced renal function. Lactic acidosis appears either as part of a number of clinical syndromes (i.e., unrelated to metformin), induced by metformin (involving an analysis of the drug's pharmacokinetics and mechanisms of action), or associated with metformin (a more complex situation, as lactic acidosis in a metformin-treated patient is not necessarily accompanied by metformin accumulation, nor does metformin accumulation necessarily lead to lactic acidosis). A critical analysis of guidelines and literature data on metformin therapy in patients with CKD is presented. Following the present focus on metformin, new paradoxical issues can be drawn up, in particular: (i) metformin is rarely the sole cause of lactic acidosis; (ii) lactic acidosis in patients receiving metformin therapy is erroneously still considered a single medical entity, as several different scenarios can be defined, with contrasting prognoses. The prognosis for severe lactic acidosis seems even better in metformin-treated patients than in non-metformin users.
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Affiliation(s)
- Jean-Daniel Lalau
- 1] Service d'Endocrinologie et de Nutrition, Centre Hospitalier Universitaire, Amiens, France [2] Unité INSERM U-1088, Université de Picardie Jules Verne, Amiens, France
| | - Paul Arnouts
- Department of Nephrology-Diabetology-Endocrinology, AZ Turnhout, Turnhout, Belgium
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Renal Institute of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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Vecchio S, Giampreti A, Petrolini VM, Lonati D, Protti A, Papa P, Rognoni C, Valli A, Rocchi L, Rolandi L, Manzo L, Locatelli CA. Metformin accumulation: Lactic acidosis and high plasmatic metformin levels in a retrospective case series of 66 patients on chronic therapy. Clin Toxicol (Phila) 2013; 52:129-35. [DOI: 10.3109/15563650.2013.860985] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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De Backer D. Year in review 2012: Critical Care--Cardiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:247. [PMID: 24267398 PMCID: PMC4059378 DOI: 10.1186/cc13127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this review I discuss key research papers in cardiology and intensive care published in Critical Care during 2012 with related studies published in other journals quoted whenever appropriate. These studies are grouped into the following categories: cardiovascular therapies, mechanical therapies, pathophysiologic mechanisms, hemodynamic monitoring, ultrasound in respiratory failure, microcirculation, and miscellaneous.
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Blood lactate concentration after exposure to conducted energy weapons (including TASER® devices): is it clinically relevant? Forensic Sci Med Pathol 2013; 9:386-94. [PMID: 23605975 DOI: 10.1007/s12024-013-9436-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2013] [Indexed: 10/26/2022]
Abstract
In previous studies, blood lactate concentration (BLac) consistently increased in anesthetized animals and in human subjects after exposures to TASER(®) conducted energy weapons (CEWs). Some have suggested the increased BLac would have detrimental consequences. In the current review, the following are evaluated: (a) the nature of muscle contractions due to CEWs, (b) general aspects of increased BLac, (c) previous studies of conventional neuromuscular electrical stimulation and CEW exposures, and (d) BLac in disease states. On the basis of these analyses, one can conclude that BLac, per se (independent of acidemia), would not be clinically relevant immediately after short-duration CEW applications, due to the short time course of any increase.
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The Role of Metformin in Metformin-Associated Lactic Acidosis (MALA): Case Series and Formulation of a Model of Pathogenesis. Drug Saf 2013; 36:733-46. [DOI: 10.1007/s40264-013-0038-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Does metformin-associated lactic acidosis really exist? Despite an old controversy, there is no doubt about it. But do we understand what is going on? Laboratory findings raised several hypotheses explaining the pathophysiology of this disease. The main cause could be an inhibition of either gluconeogenesis or mitochondrial respiratory chain complex I. From bench to bedside, one hypothesis is now confirmed in humans. Metformin poisoning involves, at least partially, a mitochondrial dysfunction.
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Affiliation(s)
- Jean-Christophe Orban
- Service de Réanimation Médico-chirurgicale, Hôpital Saint-Roch, Centre Hospitalier Universitaire de Nice, 5 rue Pierre Dévoluy, 06006 Nice, France
- IRCAN, Faculté de Médecine, Université de Nice, Avenue de Valombrose, 06107 Nice, France
| | - Eric Fontaine
- INSERM, U1055, 2280 rue de la piscine, 38041 Grenoble, France
| | - Carole Ichai
- Service de Réanimation Médico-chirurgicale, Hôpital Saint-Roch, Centre Hospitalier Universitaire de Nice, 5 rue Pierre Dévoluy, 06006 Nice, France
- IRCAN, Faculté de Médecine, Université de Nice, Avenue de Valombrose, 06107 Nice, France
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Protti A, Lecchi A, Fortunato F, Artoni A, Greppi N, Vecchio S, Fagiolari G, Moggio M, Comi GP, Mistraletti G, Lanticina B, Faraldi L, Gattinoni L. Metformin overdose causes platelet mitochondrial dysfunction in humans. Crit Care 2012; 16:R180. [PMID: 23034133 PMCID: PMC3682281 DOI: 10.1186/cc11663] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/10/2012] [Accepted: 08/31/2012] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION We have recently demonstrated that metformin intoxication causes mitochondrial dysfunction in several porcine tissues, including platelets. The aim of the present work was to clarify whether it also causes mitochondrial dysfunction (and secondary lactate overproduction) in human platelets, in vitro and ex vivo. METHODS Human platelets were incubated for 72 hours with saline or increasing doses of metformin (in vitro experiments). Lactate production, respiratory chain complex activities (spectrophotometry), mitochondrial membrane potential (flow-cytometry after staining with JC-1) and oxygen consumption (Clark-type electrode) were then measured. Platelets were also obtained from ten patients with lactic acidosis (arterial pH 6.97 ± 0.18 and lactate 16 ± 7 mmol/L) due to accidental metformin intoxication (serum drug level 32 ± 14 mg/L) and ten healthy volunteers of similar sex and age. Respiratory chain complex activities were measured as above (ex vivo experiments). RESULTS In vitro, metformin dose-dependently increased lactate production (P < 0.001), decreased respiratory chain complex I activity (P = 0.009), mitochondrial membrane potential (P = 0.003) and oxygen consumption (P < 0.001) of human platelets. Ex vivo, platelets taken from intoxicated patients had significantly lower complex I (P = 0.045) and complex IV (P < 0.001) activity compared to controls. CONCLUSIONS Depending on dose, metformin can cause mitochondrial dysfunction and lactate overproduction in human platelets in vitro and, possibly, in vivo. TRIAL REGISTRATION NCT 00942123.
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Affiliation(s)
- Alessandro Protti
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Anna Lecchi
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Francesco Fortunato
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Andrea Artoni
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Noemi Greppi
- Centro Trasfusionale e di Immunoematologia, Dipartimento di Medicina Rigenerativa, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Sarah Vecchio
- Centro Nazionale di Informazione Tossicologica - Centro Antiveleni, Fondazione IRCCS Salvatore Maugeri, via S. Maugeri 10/10A, 27100 Pavia, Italy
| | - Gigliola Fagiolari
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Maurizio Moggio
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Giacomo Pietro Comi
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Giovanni Mistraletti
- U.O. Anestesia e Rianimazione, A.O. San Paolo, Università degli Studi di Milano, via A. Di Rudiní 8, 20142 Milan, Italy
| | - Barbara Lanticina
- U.O. Rianimazione, A.O. San Carlo Borromeo, via Pio II 3, 20147 Milan, Italy
| | - Loredana Faraldi
- Servizio Anestesia e Rianimazione 1°, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
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Tsaknis G, Siempos II, Kopterides P, Maniatis NA, Magkou C, Kardara M, Panoutsou S, Kotanidou A, Roussos C, Armaganidis A. Metformin attenuates ventilator-induced lung injury. Crit Care 2012; 16:R134. [PMID: 22827994 PMCID: PMC3580719 DOI: 10.1186/cc11439] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/01/2012] [Accepted: 07/24/2012] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Diabetic patients may develop acute lung injury less often than non-diabetics; a fact that could be partially ascribed to the usage of antidiabetic drugs, including metformin. Metformin exhibits pleiotropic properties which make it potentially beneficial against lung injury. We hypothesized that pretreatment with metformin preserves alveolar capillary permeability and, thus, prevents ventilator-induced lung injury. METHODS Twenty-four rabbits were randomly assigned to pretreatment with metformin (250 mg/Kg body weight/day per os) or no medication for two days. Explanted lungs were perfused at constant flow rate (300 mL/min) and ventilated with injurious (peak airway pressure 23 cmH₂O, tidal volume ≈17 mL/Kg) or protective (peak airway pressure 11 cmH₂O, tidal volume ≈7 mL/Kg) settings for 1 hour. Alveolar capillary permeability was assessed by ultrafiltration coefficient, total protein concentration in bronchoalveolar lavage fluid (BALF) and angiotensin-converting enzyme (ACE) activity in BALF. RESULTS High-pressure ventilation of the ex-vivo lung preparation resulted in increased microvascular permeability, edema formation and microhemorrhage compared to protective ventilation. Compared to no medication, pretreatment with metformin was associated with a 2.9-fold reduction in ultrafiltration coefficient, a 2.5-fold reduction in pulmonary edema formation, lower protein concentration in BALF, lower ACE activity in BALF, and fewer histological lesions upon challenge of the lung preparation with injurious ventilation. In contrast, no differences regarding pulmonary artery pressure and BALF total cell number were noted. Administration of metformin did not impact on outcomes of lungs subjected to protective ventilation. CONCLUSIONS Pretreatment with metformin preserves alveolar capillary permeability and, thus, decreases the severity of ventilator-induced lung injury in this model.
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Affiliation(s)
- George Tsaknis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Ilias I Siempos
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Petros Kopterides
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Nikolaos A Maniatis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Christina Magkou
- Department of Histopathology, Evangelismos Hospital, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Matina Kardara
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Stefania Panoutsou
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Anastasia Kotanidou
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- First Department of Critical Care and Pulmonary Services, "Evangelismos" Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Charis Roussos
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- First Department of Critical Care and Pulmonary Services, "Evangelismos" Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Apostolos Armaganidis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
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