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Lactic Acidosis – Causes, Symptoms and Treatment
Lactic acidosis is a dangerous condition in which lactic acid builds up in the bloodstream, causing the blood to become too acidic. It requires immediate medical attention.
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Lactic acidosis is a dangerous condition in which lactic acid builds up in the bloodstream, causing the blood to become too acidic. It requires immediate medical attention.
What is Lactic Acidosis?
Lactic acidosis is a serious form of metabolic acidosis caused by the excessive accumulation of lactate (lactic acid) in the blood. Lactate is a normal byproduct of glucose metabolism when oxygen levels are insufficient (anaerobic metabolism). In a healthy individual, lactate is rapidly cleared by the liver. When blood lactate levels exceed 5 mmol/l and the blood pH drops below 7.35, the condition is classified as lactic acidosis.
Causes
Lactic acidosis is commonly divided into two main types:
Type A – Hypoxic Lactic Acidosis
This form is caused by insufficient oxygen delivery to the tissues (hypoxia). Common triggers include:
- Shock states (e.g., septic, cardiogenic, or hemorrhagic shock)
- Severe heart failure or cardiac arrest
- Severe anemia
- Respiratory failure and severe lung disease
- Intense physical exertion
Type B – Non-Hypoxic Lactic Acidosis
This form occurs without direct oxygen deprivation and has a variety of causes:
- Medications: especially metformin (an antidiabetic drug), but also certain antiretroviral agents (HIV medications) and linezolid
- Liver disease, as the liver is responsible for clearing lactate
- Kidney failure
- Certain cancers (leukemia, lymphomas)
- Inherited metabolic disorders (e.g., mitochondrial diseases)
- Poisoning, e.g., from alcohol, cyanide, or carbon monoxide
Symptoms
The symptoms of lactic acidosis often develop rapidly and may be non-specific. Typical signs include:
- Nausea, vomiting, and abdominal pain
- Weakness and general malaise
- Rapid, deep breathing (Kussmaul breathing) as the body attempts to compensate for the acidosis
- Rapid heart rate (tachycardia)
- Low blood pressure
- Confusion, dizziness, or loss of consciousness
- In severe cases: organ failure
Diagnosis
The diagnosis is confirmed by an arterial blood gas analysis (ABG). Key values measured include:
- Blood lactate concentration (elevated, above 5 mmol/l in lactic acidosis)
- Blood pH (reduced, below 7.35)
- Bicarbonate (HCO₃⁻): decreased
- Base excess: strongly negative
Additional tests include a complete blood count, kidney and liver function tests, blood glucose, and a thorough medication history to identify the underlying cause.
Treatment
Treatment of lactic acidosis depends on the underlying cause and typically requires intensive care unit (ICU) management:
- Treating the underlying cause: This is the top priority. Shock is managed aggressively; if metformin is the cause, it is immediately discontinued.
- Oxygen therapy: Ensuring adequate tissue oxygenation
- Intravenous fluids: To stabilize circulation and blood pressure
- Sodium bicarbonate: May be used in severe cases to buffer the acidosis, though its efficacy remains debated
- Dialysis (renal replacement therapy): Hemodialysis may be required in severe cases, particularly in metformin toxicity or renal failure
- Continuous intensive monitoring and organ support
Prognosis
Lactic acidosis is a potentially life-threatening condition. Mortality rates vary depending on the cause and severity; Type A lactic acidosis is associated with particularly high mortality. Early diagnosis and prompt treatment of the underlying condition are critical to improving outcomes.
References
- Kraut, J. A. & Madias, N. E. (2014). Lactic acidosis. New England Journal of Medicine, 371(24), 2309–2319. https://doi.org/10.1056/NEJMra1309483
- World Health Organization (WHO): Metformin and lactic acidosis – Safety information. WHO Pharmaceuticals Newsletter.
- Tintinalli, J. E. et al. (2020). Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th edition. McGraw-Hill Education.
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