(See also Metabolic Acidosis Metabolic Acidosis Metabolic acidosis is primary reduction in bicarbonate (HCO3−), typically with compensatory reduction in carbon dioxide partial pressure (Pco2); pH may be markedly low or slightly... read more , Acid-Base Regulation Acid-Base Regulation Metabolic processes continually produce acid and, to a lesser degree, base. Hydrogen ion (H+) is especially reactive; it can attach to negatively charged proteins and, in high concentrations... read more , and Acid-Base Disorders Acid-Base Disorders Acid-base disorders are pathologic changes in carbon dioxide partial pressure (Pco2) or serum bicarbonate (HCO3−) that typically produce abnormal arterial pH values. Acidemia is serum... read more .)
Lactate is a normal byproduct of glucose and amino acid metabolism. There are 2 main types of lactic acidosis:
Type A lactic acidosis
Type B lactic acidosis
D-Lactic acidosis (D-lactate encephalopathy) is an unusual form of lactic acidosis.
Type A lactic acidosis
Type A lactic acidosis, the most serious form, occurs when lactic acid is overproduced in ischemic tissue—as a byproduct of anaerobic generation of ATP (adenosine triphosphate) during oxygen deficit. Overproduction typically occurs during global tissue hypoperfusion in hypovolemic Hypovolemic shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more , cardiogenic Cardiogenic shock Numerous complications can occur as a result of an acute coronary syndrome and increase morbidity and mortality. Complications can be roughly categorized as Electrical dysfunction (conduction... read more 
, or septic shock Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more and is worsened by decreased lactate metabolism in the poorly perfused liver. It may also occur with primary hypoxia due to lung disease and with various hemoglobinopathies Overview of Hemoglobinopathies Hemoglobinopathies are genetic disorders affecting the structure or production of the hemoglobin molecule. Hemoglobin molecules consist of polypeptide chains whose chemical structure is genetically... read more .
Type B lactic acidosis
Type B lactic acidosis occurs in states of normal global tissue perfusion (and hence ATP production) and is less ominous.
Causes include local tissue hypoxia (eg, as with vigorous muscle use during exertion, seizures, hypothermic shivering), certain systemic and congenital conditions, cancer, and ingestion of certain drugs or toxins (see table Causes of Metabolic Acidosis Causes of Metabolic Acidosis 
). Drugs include the nucleoside reverse transcriptase inhibitors and the biguanides phenformin and, less so, metformin; although phenformin has been removed from the market in most of the world, it is still available from China (including as a component of some Chinese proprietary medicines). Metabolism may be decreased due to hepatic insufficiency or thiamin deficiency.
D-Lactic acidosis
D-Lactic acidosis is an unusual form of lactic acidosis in which D-lactic acid, the product of bacterial carbohydrate metabolism in the colon of patients with jejunoileal bypass or intestinal resection, is systemically absorbed. It persists in circulation because human lactate dehydrogenase can metabolize only L-lactate.
Symptoms and Signs
Symptoms and signs of lactic acidosis are dominated by those of the underlying disorder (eg, shock in Type A, toxin ingestion in Type B). Neurologic symptoms, including confusion, ataxia, and slurred speech, occur after a high-carbohydrate ingestion and are characteristic of D-lactic acidosis.
Diagnosis
Arterial blood gas (ABG) and serum electrolyte measurements
Anion gap and delta gap calculated
Blood lactate level
ABG values in types A and B lactic acidosis are as for other metabolic acidoses Diagnosis Metabolic acidosis is primary reduction in bicarbonate (HCO3−), typically with compensatory reduction in carbon dioxide partial pressure (Pco2); pH may be markedly low or slightly... read more . Diagnosis requires blood pH < 7.35 and lactate > 45 to 54 mg/dL (> 5 to 6 mmol/L). Less extreme lactate and pH changes are referred to as hyperlacticemia.
In D-lactic acidosis, the anion gap is lower than expected for the decrease in bicarbonate (HCO3−), and there may be a urinary osmolar gap (difference between calculated and measured urine osmolarity). Typical laboratory lactate assays are not sensitive to D-lactate. Specific D-lactate levels are available and sometimes needed to clarify the cause of acidosis in patients with multiple potential causes including bowel problems.
Treatment
Treatment of cause
Treatment of types A and B lactic acidosis is similar to treatment of other metabolic acidoses Treatment Metabolic acidosis is primary reduction in bicarbonate (HCO3−), typically with compensatory reduction in carbon dioxide partial pressure (Pco2); pH may be markedly low or slightly... read more .
Treatment of the cause is paramount. In treating inadequate tissue perfusion, pressors should be omitted when possible because they may worsen tissue ischemia. Bicarbonate is potentially dangerous in high anion gap acidosis but may be considered when pH is < 7.00, with a target pH of ≤ 7.10.
In D-lactic acidosis, treatment is IV fluids, restriction of carbohydrates, and sometimes oral antibiotics (eg, metronidazole) for short bowel syndrome and bicarbonate for severe acidosis.
Key Points
There are 2 main types of lactic acidosis, type A and type B; type A is more serious because it is caused by ischemia.
Diagnosis requires blood pH < 7.35 and serum lactate levels > 45 to 54 mg/dL (> 5 to 6 mmol/L).
Avoid pressors when possible for types A and B lactic acidosis because they worsen tissue ischemia.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
metformin |
Fortamet, Glucophage, Glucophage XR, Glumetza, Riomet, RIOMET ER |
metronidazole |
Flagyl, Flagyl ER, Flagyl RTU, MetroCream, MetroGel, MetroGel Vaginal, MetroLotion, Noritate, NUVESSA, Nydamax, Rosadan, Rozex, Vandazole, Vitazol |
