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Hyperlactatemia – Causes, Symptoms and Treatment

Hyperlactatemia refers to an elevated lactate level in the blood and may indicate impaired oxygen supply or a metabolic disorder.

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Things worth knowing about "Hyperlactatemia"

Hyperlactatemia refers to an elevated lactate level in the blood and may indicate impaired oxygen supply or a metabolic disorder.

What is Hyperlactatemia?

Hyperlactatemia describes an abnormally elevated concentration of lactate (lactic acid) in the blood. Lactate is a metabolic byproduct produced when cells generate energy without sufficient oxygen (anaerobic glycolysis). Under normal conditions, venous blood lactate levels remain below 2 mmol/l. Hyperlactatemia is defined as lactate levels between 2 and 5 mmol/l, while values exceeding 5 mmol/l – particularly when accompanied by a reduced blood pH – are classified as lactic acidosis, a potentially life-threatening condition.

Causes

The causes of hyperlactatemia are generally divided into two main categories:

Type A – Tissue Hypoxia (Oxygen Deficiency)

Shock states (septic, cardiogenic, hemorrhagic)
Heart failure with reduced cardiac output
Severe anemia
Acute respiratory failure
Carbon monoxide poisoning

Type B – Without Primary Tissue Hypoxia

Liver disease (impaired lactate clearance)
Diabetes mellitus and diabetic ketoacidosis
Medications (e.g., metformin, antiretroviral agents, propofol)
Malignancies (Warburg effect)
Inherited metabolic disorders
Intense physical exercise (physiological, transient)

Symptoms

Mild hyperlactatemia is often asymptomatic. As lactate levels rise or progress to lactic acidosis, the following symptoms may occur:

Nausea and vomiting
Weakness and fatigue
Rapid, deep breathing (Kussmaul breathing)
Confusion and altered consciousness
Abdominal pain
In severe cases: circulatory failure and loss of consciousness

Diagnosis

Diagnosis is established through blood gas analysis (BGA) or laboratory measurement of lactate levels in venous or arterial blood. Simultaneous assessment of pH and bicarbonate helps identify accompanying acidosis. Additional investigations to determine the underlying cause may include:

Complete blood count and inflammatory markers (CRP, procalcitonin)
Liver function tests (AST, ALT, bilirubin)
Renal function parameters (creatinine, urea)
Blood glucose and ketone bodies
Imaging (ultrasound, X-ray, CT) based on clinical suspicion

Treatment

Treatment is always directed at the underlying cause:

Oxygen supplementation in cases of hypoxia or respiratory failure
Fluid resuscitation and hemodynamic stabilization in shock
Antibiotics for septic causes
Discontinuation of causative medications (e.g., metformin in renal failure)
Treatment of the underlying disease (e.g., optimized diabetes management, liver therapy)
In severe lactic acidosis: intensive care management, potentially including renal replacement therapy

Sodium bicarbonate infusion to buffer the acidosis alone is controversial and generally reserved for specific clinical scenarios, as it does not address the root cause.

References

Kruse O, Grunnet N, Barfod C. Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review. Scand J Trauma Resusc Emerg Med. 2011;19:74.
Adeva-Andany M et al. Comprehensive review on lactate metabolism in human health. Mitochondrion. 2014;17:76–100.
Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Intensive Care Med. 2017;43(3):304–377.

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