{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T16:26:43Z","timestamp":1791563203541,"version":"4.3.4"},"reference-count":24,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2023,9,30]],"date-time":"2023-09-30T00:00:00Z","timestamp":1696032000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Hemodialysis International"],"published-print":{"date-parts":[[2024,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>Metformin is widely considered a first\u2010line antiglycemic agent due to its cost\u2010effectiveness and favorable adverse effect profile. However, its use is prohibited in patients with an estimated glomerular filtration rate &lt;30\u2009mL\/min\/1.73\u2009m<jats:sup>2<\/jats:sup>, due to the risk of potentially lethal metformin\u2010associated lactic acidosis (MALA). We sought to evaluate MALA cases and outcomes at our institution.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>In this observational, retrospective case series, we reviewed our EMR for all patients who had a metformin level drawn between January 2013 and May 2022 to identify individuals who met the diagnostic criteria for MALA. We evaluated risk factors for MALA, the relationship between metformin level, blood pH, serum bicarbonate, and lactate level and clinical outcomes of ventilator dependency, renal replacement therapy requirement, renal recovery in acute kidney injury (AKI) patients, and survival.<\/jats:p><\/jats:sec><jats:sec><jats:title>Findings<\/jats:title><jats:p>A total of 107 patients had metformin levels drawn, of which 19 patients met the diagnostic criteria for MALA. In our case series, MALA was primarily seen in AKI (15 patients) secondary to dehydration and sepsis, followed by end\u2010stage renal disease (ESRD) (4 patients). Intubation was required in 17 patients, of whom 8 were successfully extubated after a mean duration of 14\u2009days. Sixteen patients received renal replacement therapy (RRT). Intermittent hemodialysis (IHD) was performed in nine, continuous renal replacement therapy (CRRT) in four, and sequential therapy of IHD and CRRT in three patients. Seven patients, all in the AKI group (46.7%), died while all ESRD patients survived, accounting for an overall mortality rate of 36.8%. Among the eight surviving AKI patients, four had complete renal recovery with renal function returning to baseline, three had partial renal recovery, and one continued to require IHD at the time of discharge to a rehabilitation facility.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>MALA may be an underrecognized entity. A high level of clinical suspicion leading to prompt and aggressive treatment with RRT may improve mortality rates. Provider and patient education is of paramount importance for safe use of metformin.<\/jats:p><\/jats:sec>","DOI":"10.1111\/hdi.13113","type":"journal-article","created":{"date-parts":[[2023,9,30]],"date-time":"2023-09-30T08:38:55Z","timestamp":1696063135000},"page":"32-39","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Metformin\u2010associated lactic acidosis (<scp>MALA<\/scp>): Is it an underestimated entity? A retrospective, single\u2010center case series"],"prefix":"10.1111","volume":"28","author":[{"given":"Susan","family":"Kim","sequence":"first","affiliation":[{"name":"Division of Nephrology Lincoln Medical Center  Bronx New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amara","family":"Sarwal","sequence":"additional","affiliation":[{"name":"Division of Nephrology &amp; Hypertension University of Utah  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xin Tan","family":"Yee","sequence":"additional","affiliation":[{"name":"Division of Nephrology Lincoln Medical Center  Bronx New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian A. Gandarillas","family":"Fraga","sequence":"additional","affiliation":[{"name":"Division of Nephrology Lincoln Medical Center  Bronx New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent","family":"Campion","sequence":"additional","affiliation":[{"name":"Division of Nephrology Lincoln Medical Center  Bronx New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Isaiarasi","family":"Gnanasekaran","sequence":"additional","affiliation":[{"name":"Division of Nephrology Lincoln Medical Center  Bronx New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2023,9,30]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-017-4318-z"},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-022-07899-2"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD003053"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.3892\/br.2012.18"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2006-0336"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.3389\/fendo.2020.00191"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.biopha.2021.111454"},{"issue":"4","key":"e_1_2_6_9_1","article-title":"Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus","volume":"2010","author":"Salpeter SR","year":"2010","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_6_10_1","doi-asserted-by":"publisher","DOI":"10.2337\/dc13-3023"},{"key":"e_1_2_6_11_1","volume-title":"Glucophage (metformin hydrochloride) and Glucophage XR (extended\u2010release) prescribing information","year":"2009"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.1111\/dom.12974"},{"key":"e_1_2_6_13_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11255-009-9549-6"},{"key":"e_1_2_6_14_1","volume-title":"StatPearls","author":"Dogra P","year":"2022"},{"key":"e_1_2_6_15_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamasurg.2020.0416"},{"key":"e_1_2_6_16_1","doi-asserted-by":"publisher","DOI":"10.14740\/jem350w"},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.14107"},{"key":"e_1_2_6_18_1","doi-asserted-by":"publisher","DOI":"10.3747\/pdi.2013.00048"},{"key":"e_1_2_6_19_1","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2013.301823"},{"key":"e_1_2_6_20_1","doi-asserted-by":"publisher","DOI":"10.1097\/CCM.0000000000001002"},{"key":"e_1_2_6_21_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199801223380415"},{"key":"e_1_2_6_22_1","doi-asserted-by":"publisher","DOI":"10.1159\/000471917"},{"key":"e_1_2_6_23_1","doi-asserted-by":"publisher","DOI":"10.1186\/cc7137"},{"key":"e_1_2_6_24_1","doi-asserted-by":"publisher","DOI":"10.1007\/s40620-020-00941-8"},{"key":"e_1_2_6_25_1","doi-asserted-by":"publisher","DOI":"10.1007\/s13181-020-00802-7"}],"container-title":["Hemodialysis International"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/hdi.13113","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,1,22]],"date-time":"2024-01-22T07:22:49Z","timestamp":1705908169000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/hdi.13113"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,30]]},"references-count":24,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2024,1]]}},"alternative-id":["10.1111\/hdi.13113"],"URL":"https:\/\/doi.org\/10.1111\/hdi.13113","archive":["Portico"],"relation":{},"ISSN":["1492-7535","1542-4758"],"issn-type":[{"value":"1492-7535","type":"print"},{"value":"1542-4758","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,30]]},"assertion":[{"value":"2023-02-19","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2023-09-18","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2023-09-30","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}