# 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.

## Key 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.