Can you treat lactic acidosis by dialysis?

      10 Comments on Can you treat lactic acidosis by dialysis?

Managing patients with lactic acidosis, especially the type A variety, is really hard! Usually they have multiple problems, are septic, hypotensive, often on multiple machines and the lactate keeps going up. The choices are between giving soda bicarb, carbicarb or dichloroacetate. The main purpose is to avoid some of complications of severe acidosis such arrhythmias, decreased response to cathechloamines, or reduced contractility. Bicarbonate therapy is a double-edged sword, however, because of the several side-effects such as decreased cardiac output, reduced ionized cardiac output, increased CO2 generation, volume overload and increased lactate generation. Paradoxically, it can also worsen intracellular acidosis.

Staff managing these patients think that it would be great to simply clear it out using an extracorporeal therapy, such as hemodialysis or CRRT.

Unfortunately it usually does not work. Lactate clearance by dialysis is only 3% of the overall clearance, most of which is in the tissue. In one study, they evaluated the utility of continuous venovenous hemofiltration with dialysis, to calculate lactate clearance by the hemofilter in 10 critically ill patients with acute renal failure and stable blood lactate concentrations. They found that the median blood lactate concentration increased despite renal replacement therapy. The median total plasma lactate clearance was 1379 ml/min (range, 754 to 1881 ml/min), and the median filter lactate clearance was 24 ml/min (range, 7 to 36 ml/min). The authors concluded that continuous venovenous hemofiltration with dialysis cannot meet lactate overproduction.

Moreover, the generation of lactic acid is at least order of magnitude greater than the clearance.

The only situation where dialysis has been helpful in management of lactic acidosis is when it is secondary to metformin therapy – even there opinions are divided.

This is not to say extracorporeal therapies are not indicated in patients with lactic acidosis: it can help by volume management, cytokine removal and other mechanisms that can indirectly reduce lactic acid production.

Some informative articles are here, herehere, and here.

10 thoughts on “Can you treat lactic acidosis by dialysis?

  1. Rahul sood

    Sir as you suggest PD is under -utilised in these patients, but is PD will be helpful for these patient with fluid over load and in shock when likely there will be low peritoneal capillary perfusion.

    Reply
    1. vjha Post author

      In a RCT of PD and SLEDD in ICU patients, both were found equally effective. Click here to read the paper. Over 80% patients were on mechanical ventilation and most were on inotropes. So this fear is not based on facts.

      The second point is that the idea is not to say one therapy is better than the other, only that we should be judicious in making a choice. If I had a patient with hepatic failure or head trauma who needed RRT and if CRRT was not available, I would not hesitate in using PD.

      You should ideally have the choice of all forms of RRT and freely choose, or shift from one to the other therapy as needed.

      Reply
  2. ajay jaryal

    sir, RRT may not be effective in removing lactate but if acidosis is severe it might help in improving metabolic acidosis by adding bicarbonate to circulation without leading to volume overload, as net pH is considered responsible for arrhythmia and cardiac hypocontractility.

    Reply
    1. vjha Post author

      Yes you are right but if I may unpack your answer – please note you are suggesting dialysis for avoiding fluid overload not treatment of acidosis.

      Reply
  3. Joyita

    Would someone with lactic acidosis because of sepsis/shock with MODS (liver failure) benefit from peritoneal dialysis (if otherwise indicated and CRRT not being a feasible option)? Is there a scope of bicarbonate based PD?

    Reply
    1. vjha Post author

      Sure, PD is a very good but under-utilized RRT option in this situation, considering the risk of worsening of intracranial pressure associated with HD.

      A point I hoped to make, and will do so again, is that there is very little contribution of dialysis either in clearance, or in adding to the existing lactate lead, considering the pathogenesis, so we should not worry about the relatively small amount of lactate in the PD fluid.

      The best way to give bicarbonate, if it is indicated, is by vein. We know exactly how much went in. A point to be reiterated that bicarb may not be of much help, unless the pH is very low.

      Reply
  4. NISITH Kumar Mohanty

    that is why even after 6 to eight hour SLEED /HD acidosis rarely or little corrected in a severe septic shock with lactic acidosis,rebound acidosis is very common after HD/SLEED accusing the Nephrologist saying your dialysis is not good or effective
    DR NISITH KUMAR MOHANTY
    CHIEF CONSULTANT NEPHROLOGY
    APOLLO HOSPITAL BHUBANESWAR
    nkmty2002@ gmail.com

    Reply

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