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ÇİFTÇİOĞLU M. Shouldn't Stage 4 And 5 Chronic Kidney Disease Patients Use Metformin? KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2022. [DOI: 10.17517/ksutfd.1181458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Metformin is the first place anti-diabetic agent recommended with life style changes in many guidelines for the treatment of patients with type 2 diabetes mellitus (DM). The mechanism of effect of the drug is to increase insulin sensitivity in peripheral tissue and reduce glucose secretion from the liver. Metformin is a low cost, effective and safe drug. Although its frequent side effects are gastrointestinal side effects and the most feared side effect is lactic acidosis. Due to this side effect, its use is limited in many guidelines in patients with chronic kidney disease (CKD). In this article, we examined the use of metformin in all stages of CKD. We investigated the incidence of metformin-associated lactic acidosis (MALA). Shouldn't stage 4 and 5 chronic kidney disease patients use metformin? We sought an answer to question. As a result, we decided that side effects like MALA are extremely rare. We observed that these side effects occur mostly in the presence of diseases in which tissue perfusion is impaired such as infections, serious cardiovascular events, and hypotension. We came to the conclusion that metformin should be used in patients with stage 4 and 5 CKD patients, without much fear, considering the profit and loss relationship.
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Orloff J, Min JY, Mushlin A, Flory J. Safety and effectiveness of metformin in patients with reduced renal function: A systematic review. Diabetes Obes Metab 2021; 23:2035-2047. [PMID: 34009711 DOI: 10.1111/dom.14440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
AIM To examine clinical and safety outcomes associated with metformin use in patients with impaired renal function. MATERIALS AND METHODS We searched PubMed and Embase databases from inception to August 2020, supplementing our search with a review of investigator files and reference lists of included studies. Any study reporting original data on metformin and patient-centred outcomes in patients with impaired renal function, defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 , was included. Post hoc meta-analysis was performed for the outcomes of mortality, cardiovascular events and acidosis. RESULTS Nine small prospective studies enrolling patients with significantly impaired renal function identified only one case of clinically apparent lactic acidosis. Among 13 larger retrospective studies, seven examined the risk of mortality across patient subgroups; meta-analysis showed reductions in overall mortality at an eGFR of 45 mL/min/1.73m2 or higher but not at an eGFR of less than 45 mL/min/1.73m2 . Eight retrospective studies evaluated acidosis as an outcome; meta-analysis showed no increase in risk of acidosis except at an eGFR of less than 30 mL/min/1.73m2 , in which group the HR was 1.97 (95% CI 1.03-3.77). CONCLUSIONS The literature shows metformin to be associated with reduced mortality and no increased risk of acidosis at an eGFR of 45 mL/min/1.73m2 or higher. Metformin appears to be associated with fewer benefits and possible increases in the risk of acidosis at an eGFR of less than 30 mL/min/1.73m2 . Consistent with US Food and Drug Administration guidelines, metformin should not be used at an eGFR less than 30 mL/min/1.73m2 , and further research on its risk-benefit profile at eGFR values approaching 30 mL/min/1.73m2 is warranted.
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Affiliation(s)
- Jeremy Orloff
- Weill Cornell Medical College, New York, New York, USA
| | - Jea Young Min
- Weill Cornell Medical College, New York, New York, USA
| | - Alvin Mushlin
- Weill Cornell Medical College, New York, New York, USA
| | - James Flory
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Phillips J, Chen JHC, Ooi E, Prunster J, Lim WH. Global Epidemiology, Health Outcomes, and Treatment Options for Patients With Type 2 Diabetes and Kidney Failure. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2021; 2:731574. [PMID: 36994340 PMCID: PMC10012134 DOI: 10.3389/fcdhc.2021.731574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/29/2021] [Indexed: 12/15/2022]
Abstract
The burden of type 2 diabetes and related complications has steadily increased over the last few decades and is one of the foremost global public health threats in the 21st century. Diabetes is one of the leading causes of chronic kidney disease and kidney failure and is an important contributor to the cardiovascular morbidity and mortality in this population. In addition, up to one in three patients who have received kidney transplants develop post-transplant diabetes, but the management of this common complication continues to pose a significant challenge for clinicians. In this review, we will describe the global prevalence and temporal trend of kidney failure attributed to diabetes mellitus in both developing and developed countries. We will examine the survival differences between treated kidney failure patients with and without type 2 diabetes, focusing on the survival differences in those on maintenance dialysis or have received kidney transplants. With the increased availability of novel hypoglycemic agents, we will address the potential impacts of these novel agents in patients with diabetes and kidney failure and in those who have developed post-transplant diabetes.
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Affiliation(s)
- Jessica Phillips
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- *Correspondence: Jessica Phillips,
| | - Jenny H. C. Chen
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
- Depatment of Nephrology, Wollongong Hospital, Wollongong, NSW, Australia
| | - Esther Ooi
- School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Janelle Prunster
- Department of Renal Medicine, Cairns Hospital, Cairns, QLD, Australia
| | - Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
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Abdel Shaheed C, Carland JE, Graham GG, Stocker SL, Smith G, Hicks M, Williams KM, Furlong T, Macdonald P, Greenfield JR, Smith FC, Chowdhury G, Day RO. Is the use of metformin in patients undergoing dialysis hazardous for life? A systematic review of the safety of metformin in patients undergoing dialysis. Br J Clin Pharmacol 2019; 85:2772-2783. [PMID: 31471973 DOI: 10.1111/bcp.14107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/04/2019] [Accepted: 08/18/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS Metformin may have clinical benefits in dialysis patients; however, its safety in this population is unknown. This systematic review evaluated the safety of metformin in dialysis patients. METHODS MEDLINE, Embase, CENTRAL, PsycINFO and the Cochrane Library were searched for randomised controlled trials and observational studies evaluating metformin use in dialysis patients. Three authors reviewed the studies and extracted data. The primary outcomes were mortality, occurrence of lactic acidosis and myocardial infarction (MI) in patients taking metformin during dialysis treatment for ≥12 months (long term). Risk of bias was assessed using Risk Of Bias In Nonrandomised Studies of Interventions (ROBINS-1). Overall quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Fifteen observational studies were eligible; 7 were prospective observational studies and 8 were case reports/case series. No randomised controlled trials were identified. The 7 prospective observational studies (n = 194) reported on cautious metformin use in patients undergoing maintenance dialysis. Only 3 provided long-term follow-up data. In 2 long-term studies of metformin therapy (≤1000 mg/d) in patients undergoing peritoneal dialysis (PD), 1 reported 6 deaths (6/83; 7%) due to major cardiovascular events (3 MI) and the other reported no deaths (0/35). One long-term study of metformin therapy (250 mg to 500 mg thrice weekly) in patients undergoing haemodialysis reported 4 deaths (4/61; 7%) due to major cardiovascular events (2 MI). These findings provide very low-quality evidence as they come from small observational studies. CONCLUSION The evidence regarding the safety of metformin in people undergoing dialysis is inconclusive. Appropriately designed randomised controlled trials are needed to resolve this uncertainty.
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Affiliation(s)
- Christina Abdel Shaheed
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Greg Smith
- Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Mark Hicks
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Timothy Furlong
- Department of Nephrology, St Vincent's Hospital, Sydney, Australia
| | - Peter Macdonald
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Jerry R Greenfield
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,Diabetes and Metabolism Division, Garvan Institute of Metabolic Research, Sydney, Australia.,Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Gina Chowdhury
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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Abstract
Metformin has been associated with lactic acidosis. Lactate levels are not commonly tested in clinical practice, and it is unclear to what extent metformin would typically increase lactate levels with chronic use. The aim of this review was to determine whether regular monitoring of the plasma lactate level would be beneficial in avoiding lactate accumulation and, ultimately, minimising the incidence of lactic acidosis in metformin-treated patients.A comprehensive search of PubMed, Embase, Web of Science, Cochrane and International Pharmaceutical Abstracts databases covering the period up to 30 May 2017 was performed. Search terms included combinations of terms and keywords, including "metformin", "lactate", "lactic acid" and "lactic acidosis". Cases series of lactic acidosis or metformin-associated lactic acidosis were excluded.Of 1539 potentially relevant articles, a total of 52 reported lactate levels from routine/regular pathological tests in metformin users. The studies were subdivided into four themes, regarding metformin usage and the reported lactate levels in patients who: (1) did not have contraindications to the use of metformin; (2) had contraindications, or renal impairment but without other contraindications; (3) exercised; or (4) also received any nucleoside reverse transcriptase inhibitor. Studies have reported that metformin treatment could increase lactate level of users. However, most results showed that the lactate level remained in the normal range.No definitive conclusions on the benefits of regular lactate monitoring in patients taking metformin can be made. Future research on larger populations focusing on the measurement of lactate levels with continuous metformin use is warranted.
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Trinh E, Saiprasertkit N, Bargman JM. Increased Serum Lactate in Peritoneal Dialysis Patients Presenting with Intercurrent Illness. Perit Dial Int 2018; 38:363-365. [PMID: 29386309 DOI: 10.3747/pdi.2017.00169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/01/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Lactate is the most commonly used buffer in peritoneal dialysis (PD) solutions. While previous studies have shown that serum lactate is normal in stable PD patients, the purpose of our study was to evaluate whether abnormal lactate values are more common in PD patients presenting to the emergency department (ED) and have the same significance as in the general population. METHODS This observational cohort study assessed the prevalence of elevated serum lactate in PD patients presenting to the ED and evaluated clinical factors associated with an abnormal lactate value. RESULTS We studied 172 patient visits in 89 PD patients to the ED at a major academic center between January 1, 2015, and December 31, 2015. An initial venous blood lactate value was performed in 91 visits (53%) and was found to be elevated (> 2 mmol/L) in 26 cases (29%). While an abnormal lactate was associated with signs of hemodynamic compromise such as intensive care unit (ICU) admission (26.9% vs 10.8%, p = 0.05) and tachycardia (46.2% vs 9.2%, p < 0.01), in half of the cases with elevated lactate, there was no evidence of hemodynamic instability at initial presentation. Moreover, an abnormal lactate value was also associated with a greater likelihood of undergoing an abdominal computed tomography (CT) scan (46.2% vs 18.5%, p < 0.01), but bowel ischemia was present in only 1 case. CONCLUSION An abnormal lactate value is often seen in PD patients presenting to the ED, even in the absence of signs of hemodynamic instability, and very rarely indicates bowel ischemia. We postulate that in the setting of an acute intercurrent illness, there is a transient disruption in the metabolism of lactate absorbed from the PD fluid. This novel observation suggests that elevated serum lactate in the sick PD patient does not necessarily indicate tissue hypoperfusion or gut ischemia and may obviate unnecessary investigations.
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | | | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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