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A patient with acute liver failure and extreme hypoglycaemia with lactic acidosis who was not in a coma: causes and consequences of lactate-protected hypoglycaemia.

Anaesthesia and intensive care (2014-06-27)
G Oldenbeuving, J R McDonald, M L Goodwin, R Sayilir, D J Reijngoud, L B Gladden, M W N Nijsten
ABSTRACT

Lactate can substitute for glucose as a metabolic substrate. We report a patient with acute liver failure who was awake despite a glucose level of 0.7 mmol/l with very high lactate level of 25 mmol/l. The hypoglycaemia+hyperlactataemia combination may be considered paradoxical since glucose is the main precursor of lactate and lactate is reconverted into glucose by the Cori cycle. Literature relevant to the underlying mechanism of combined deep hypoglycaemia and severe hyperlactataemia was assessed. We also assessed the literature for evidence of protection against deep hypoglycaemia by hyperlactataemia. Four syndromes demonstrating hypoglycaemia+hyperlactataemia were found: 1) paracetamol-induced acute liver failure, 2) severe malaria, 3) lymphoma and 4) glucose-6-phosphatase deficiency. An impaired Cori cycle is a key component in all of these metabolic states. Apparently the liver, after exhausting its glycogen stores, loses the gluconeogenic pathway to generate glucose and thereby its ability to remove lactate as well. Several patients with lactic acidosis and glucose levels below 1.7 mmol/l who were not in a coma have been reported. These observations and other data coherently indicate that lactate-protected hypoglycaemia is, at least transiently, a viable state under experimental and clinical conditions. Severe hypoglycaemia+hyperlactataemia reflects failure of the gluconeogenic pathway of lactate metabolism. The existence of lactate-protected hypoglycaemia implies that patients who present with this metabolic state should not automatically be considered to have sustained irreversible brain damage. Moreover, therapies that aim to achieve hypoglycaemia might be feasible with concomitant hyperlactataemia.

MATERIALS
Product Number
Brand
Product Description

Paracetamol, European Pharmacopoeia (EP) Reference Standard
Supelco
Lactic acid, Pharmaceutical Secondary Standard; Certified Reference Material
USP
Lactic acid, United States Pharmacopeia (USP) Reference Standard
Sigma-Aldrich
Lactic acid, meets USP testing specifications
Sigma-Aldrich
Lactic acid, 85%, FCC
Sigma-Aldrich
Lactic acid, natural, ≥85%
USP
Acetaminophen, United States Pharmacopeia (USP) Reference Standard
Sigma-Aldrich
DL-Lactic acid, 85 % (w/w), syrup
Sigma-Aldrich
Acetaminophen, analytical standard
Sigma-Aldrich
Acetaminophen, BioXtra, ≥99.0%
Sigma-Aldrich
Acetaminophen, meets USP testing specifications, 98.0-102.0%, powder
Sigma-Aldrich
DL-Lactic acid, ~90% (T)
Supelco
Acetaminophen solution, 1.0 mg/mL in methanol, ampule of 1 mL, certified reference material, Cerilliant®
Sigma-Aldrich
DL-Lactic acid, JIS special grade, 85.0-92.0%
Sigma-Aldrich
DL-Lactic acid, SAJ first grade, 85.0-92.0%
Sigma-Aldrich
Lactic acid solution, ACS reagent, ≥85%
Supelco
Acetaminophen, Pharmaceutical Secondary Standard; Certified Reference Material