Metformin-Associated Lactic Acidosis Following Contrast-Induced Nephropathy

Metformin目前是治療糖尿病的首選藥物，乳酸中毒則是與Metformin治療相關的一種罕見卻可能致命的副作用。過去的個案報告裡，Metformin相關的乳酸中毒常伴隨著急性腎損傷，而在這些可能的危險因子當中，同時使用腎毒性藥物，譬如含碘顯影劑，在臨床上則是常見卻容易被忽略的。我們報告一位年老的糖尿病患最初是因為完全性的房室阻斷合併急性腎損傷而住院，經支持療法及置放暫時性心臟節律器後，腎功能於五天後恢復正常，Metformin再度被使用以改善血糖控制，同時，由於腳趾呈壞疽現象，因此安排雙下肢的電腦斷層血管攝影檢查。然而，四天之後，突發心律過慢且意識障礙，血液檢查發現急性腎衰竭合併高陰離子間隙代謝性酸中毒，經排除其他可能的致病因子，依據病史、臨床特徵及檢驗數據診斷，可能是顯影劑引發急性腎衰竭之後，導致Metformin的堆積而引起乳酸中毒。由於低血壓及呼吸衰竭，立刻使用升壓劑及呼吸器治療，且為了矯治嚴重的酸中毒以及排除乳酸及Metformin，緊急施以血液透析術。雖然在心血管、呼吸及腎臟方面的積極治療，病患仍於六天後死於敗血症。本案例提醒臨床醫師，當糖尿病患欲接受含碘顯影劑檢查時，應停止使用Metformin。對於住院病患，唯有當造影檢查結束48小時後重測的腎功能指數顯示並未惡化，才能再度使用Metformin。

關鍵字

顯影劑腎病變；乳酸中毒；急性腎損傷

並列摘要

Metformin has been recommended as the first-line therapeutic option for diabetes mellitus. Lactic acidosis is a rare but life-threatening side effect of metformin. In previously reported cases, the occurrence of metformin -associated lactic acidosis (MALA) was usually accompanied by acute kidney injury (AKI). Among these risk factors for AKI, concurrent use of nephrotoxic agent, such as contrast medium, is common but often ignored in clinical practice. We present an elderly diabetic patient who was initially hospitalized due to complete AV block associated with AKI. After supportive therapy and temporary pacemaker implantation, the renal function recovered 5 days later. Metformin was prescribed again for better glucose control; CT angiography of bilateral lower limbs was then performed to prepare for revascularization. Four days later, acute renal failure with high anion gap metabolic acidosis manifesting as bradycardia with conscious change was noted. After exclusion of other etiologies, the diagnosis of MALA following contrast medium-induced nephropathy (CIN) was made. In view of hypotension and increased respiratory distress, vasopressors and ventilator support were instituted immediately. To correct acidosis and remove lactate as well as metformin, emergent hemodialysis was also initiated within 2 hours. However, despite intensive support of cardiovascular, respiratory and renal system, the patient died of sepsis with multiple organ failure 6 days later. We present this case to remind clinicians that metformin should be discontinued in diabetic patients receiving intravascular contrast study. For hospitalized patients, metformin should only be reused if reassessed renal function 48 hours after contrast medium administration has not deteriorated.

並列關鍵字

Metformin ； Contrast-induced nephropathy ； Lactic acidosis ； Acute kidney injury

國際替代計量

Metformin-Associated Lactic Acidosis Following Contrast-Induced Nephropathy

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