Euglycemic Ketoacidosis and Lactic Acidosis Associated With Metformin Toxicity

TL;DR

This paper reports a rare case of metformin toxicity causing both lactic acidosis and euglycemic ketoacidosis in a diabetic patient with acute kidney failure.

Contribution

The paper highlights the under-recognized condition of metformin-induced euglycemic ketoacidosis in the context of acute renal failure.

Findings

Metformin toxicity can present with both lactic acidosis and euglycemic ketoacidosis.

The clinical presentation may be initially misdiagnosed as sulphonylurea-induced hypoglycemia.

A high suspicion for MALA and MALKA is needed in metformin users with acute renal failure and euglycemia.

Abstract

In patients with diabetes, diabetic ketoacidosis (DKA) is a well-documented potential complication, usually presenting with hyperglycemia, anion gap acidosis, and positive ketones. Metformin toxicity in the setting of acute renal failure is also a well-known cause of lactic acidosis. However, metformin-induced euglycemic ketoacidosis is less well-known or studied. We report a case of metformin toxicity in the setting of acute renal failure with both lactic acidosis and ketosis and an initial confounded clinical presentation of sulphonylurea-induced hypoglycemia. A high index of suspicion for metformin-associated lactic acidosis (MALA) and metformin-associated lactic acidosis with euglycemic ketoacidosis (MALKA) should be in place in patients who are taking metformin and presenting with acute renal failure and euglycemia.

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