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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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Things worth knowing about "Lactic Acidosis"

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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