Accidental metformin overdose with severe lactic acidosis and Acute Kidney Injury treated with prolonged hemodialysis P. Greco, G. Regolisti, E. Parenti, C. Maccari, R. Antoniotti, E Fiaccadori Unità Fisiopatologia Insufficienza Renale Acuta e Cronica Università degli Studi di Parma 1

History A 76-year-old man, discharged 3 days earlier after uncomplicated surgery for inguinal hernia, presented with vomiting, diarrhea, abdominal pain, hypotension, oliguria, lower abdomen and thigh hematoma Type 2 diabetes, hypertension, severe dilated cardiomyopathy (EF 20-25%), and CKD (usual sCr 1.8 mg/dL, eGFR 36 mL/min/1.73m2). Medications: metformin 1000 mg tid, ramipril 7.5 mg qd

History A 83-year-old woman was admitted for diarrhea, abdominal pain, confusion, hypotension, oliguria and pyuria Type 2 diabetes, hypertension, hypothyroidism, CAD and CKD (usual sCr 0.8 mg/dL, eGFR 50 mL/min/1.73m2) Medications: metformin 850 mg tid, zofenopril 7.5 mg bid, spironolactone 50 mg q.b

Laboratory data Patient 1 Patient 2 sGluc 221 mg/dL sCr 8.1 mg/dL, BUN 96 mg/dL sNa 136 mmol/L, sK 6.1, sCl 106 pH 6.91, PaO2 100 mmHg, PaCO2 20.8 mmHg HCO3- 5.9 mmol/L AG 27 mmol/L, lactate 17 mmol/L. sGluc 194 mg/dL sCr 5.9 mg/dL, BUN 89 mg/dL sNa 138 mmol/L, sK 4.2, sCl 88 pH 7.15, PaO2 140 mmHg, PaCO2 10 mmHg HCO3- 6 mmol/L AG 48 mmol/L, lactate 23 mmol/L

RRT indications in metformin intoxication Diane P. Calello at al. Crit Care Med 2015; 43:1716-30

Metformin: physicochemical and toxicokinetic data Diane P. Calello at al. Crit Care Med 2015; 43:1716-30

SLED and serum metformin concentration

GFR and metformin dose

MALA and mortality D. Boucaud-Maitre et al. Diabet. Med 2016 in press

MALA vs LA and mortality

Median Pharmacokinetic-toxokinetic for all techniques Diane P. Calello at al. Crit Care Med 2015; 43:1716-30