Abstract
Background
Metformin toxicity can lead to profound shock and has a high mortality rate. Supportive
care and enhanced elimination are the mainstays of therapy. Intermittent hemodialysis
(HD) produces a higher clearance of metformin than continuous veno-venous hemofiltration
or hemodiafiltration (CVVH/HDF). Nevertheless, CVVH/HDF has been proposed as an alternative
in critically ill patients with the suggestion that hypotension may limit the use
of HD.
Objective
This study sought to analyze the feasibility of performing hemodialysis in patients
with persistent shock from metformin toxicity.
Methods
We performed a 6-year (2012–2017) retrospective chart review of patients with metformin
toxicity managed at a large academic institution with a toxicology service. We included
patients with persistent shock on vasopressor support who were treated with HD. Baseline
characteristics, complications from treatment, timing of dialysis, and differences
between mean arterial pressures before, during, and at the end of dialysis were recorded
and analyzed.
Results
Despite critical mean peak lactate (23.9 mMol/L [range 17.6–27.9]), pH (6.91 [range
6.78–7.01]), and metformin levels (range 25–58 μg/mL], 6 of 7 patients recovered.
All patients required prolonged HD (mean 19 h). Upon completion of HD, hemodynamics
had improved (45 mm Hg [95% confidence interval 35–55 mm Hg] vs. 80 mm Hg [95% confidence
interval 74–86 mm Hg]) and vasopressor support decreased. Mortality in this patient
cohort was 14.3% (1/7).
Conclusion
Intermittent HD is feasible in metformin toxicity despite persistent shock and high-dose
vasopressor support. Mean arterial pressures improved during the course of HD and
high blood flow rates were tolerated.
Keywords
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Article info
Publication history
Published online: April 20, 2020
Accepted:
February 16,
2020
Received in revised form:
February 7,
2020
Received:
December 3,
2019
Footnotes
Reprints are not available from the authors.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
