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Fig. 4 | BMC Nephrology

Fig. 4

From: Serum lactate level and mortality in metformin-associated lactic acidosis requiring renal replacement therapy: a systematic review of case reports and case series

Fig. 4

The extracellular ionic compositional progression by Gamblegrams from our MALA case (The detailed information of the case was described in the Additional file 1: Figure S4). a normal physiology composition of major ions in extracellular fluid (ECF). b A 50-year-old woman case initially presented with severe lactic acidosis a few hours after suicidal metformin ingestion. Intracellular lactate was transported along with equivalent amount of protons into ECF via monocarboxylate transporters. Excess ECF protons were then buffered by bicarbonate and turned into H2O and CO2. Consequently, the increased amounts of lactate were approximately equivalent to the decreased consumption of bicarbonate. However, the failing kidney function could not replenish the consumed bicarbonate through renal ammoniagenesis or enhanced reabsorption, leading to increasingly severe acidosis. c To reverse acidosis, 622.5 mmol of sodium bicarbonate was infused to neutralize protons moving out of the cell to ECF, along with lactate. The iatrogenic hypernatremia to 168 mmol/L created an extra anion space that allowed more lactate to move from intracellular fluid to ECF, resulting in more significant hyperlactatemia

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