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Case Report
 
Metformin associated lactic acidosis complicates orthotopic liver transplantation
Andrew William Pool1, Zoka Milan2
1MBChB FRCA, ST7 Anaesthesia, King's College Hospital, Denmark Hill, London UK.
2MD, PhD, FRCA, FCIM, Consultant Anaesthetist, Honorary Senior Lecturer, Visiting Professor, King's College Hospital, London, UK.

Article ID: 100011A05AP2016
doi:10.5348/A05-2016-11-CR-7

Address correspondence to:
Zoka Milan
King's College Hospital
Denmark Hill
SE5 9RS
UK

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How to cite this article
Pool AW, Milan Z. Metformin associated lactic acidosis complicates orthotopic liver transplantation. Edorium J Anesth 2016;2:28–32.


Abstract
Introduction: We present a case of severe lactic acidosis during orthotopic liver transplant (OLT) in a 71-year-old male taking metformin for type 2 diabetes mellitus (DM). The early and unexpectedly severe lactic acidosis can be explained by metformin associated lactic acidosis (MALA), a rare and serious side effect of metformin usage not previously described during liver transplantation.
Case Report: A 71-year-old male with NASH cirrhosis and hepatocellular carcinoma presented for OLT with a background of hypertension and type 2 diabetes mellitus and estimated Glomerular Filtration Rate of 74. He received a donation after cardiac death (DCD) organ from a 60-year-old with an 8-hour cold ischemic time. Despite an uneventful anesthetic induction and relative cardiovascular stability, an unexpectedly severe lactic acidosis with pH 7.2 and a lactate of 9.7 mmol/L developed in the late dissection phase. This continued to worsen requiring intra-operative continuous veno-venous hemofiltration and prolonged ventilatory and inotropic support. The liver graft functioned satisfactorily.
Conclusion: Though lactic acidosis is common during liver transplant, the rapid onset and severity prior to the anhepatic phase despite relative cardiovascular stability is unusual. This suggests impaired lactate clearance, a key feature of MALA. The MALA is a rare condition with prevalence estimated at between one and five cases per 100,000. The mainstay of treatment is organ support and hemofiltration. Unexpected severe lactic acidosis in the absence of more common causes should lead clinicians to consider MALA, particularly in patients with underlying renal impairment.

Keywords: Liver transplant, Lactic acidosis, Metformin


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Author Contributions
Andrew William Pool – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Zoka Milan – Substantial contributions to conception and design, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Andrew William Pool et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.