Renal metabolism during four types of lactic acidosis in the dog including anoxia

The present study was undertaken to evaluate the metabolic response of the kidney to lactic acidosis. Four types of lactic acidosis were induced in the dog: infusion of lactic acid, infusion of lactic acid with phenformin, administration of phenformin alone, and hypoxia by breathing 95% nitrogen. In all groups of animals, the same degree of acidosis was observed with plasma bicarbonate ranging from 12.8 to 14.9 mM. Plasma lactate concentration ranged from 3.0 to 8.1 mumol/mL. Renal ammoniagenesis failed to be influenced by lactic acidosis. As a matter of fact, it fell during anoxia. The extraction of glutamine by the kidney rose except during anoxia where it fell. The renal production of alanine rose during the infusion of lactic acid with and without phenformin. This coincided with the extraction of glutamine. The renal extraction of lactate rose in all forms of acidosis as well as the production of pyruvate. In the renal cortical tissue, the concentration of malate, pyruvate, and lactate rose. Alanine also rose except during anoxia. An important fall in cytosolic redox potential (NAD+/NADH lactate dehydrogenase) was observed, as well as a fall in mitochondrial redox (NAD+/NADH beta-hydroxybutyrate dehydrogenase). Lactate also accumulated in the liver and in the muscle. We propose that the kidney is unable to respond to lactic acidosis in terms of ammonia production and that this phenomenon is explained by transamination of pyruvate and glutamate into alanine and also by the observed fall in cytosolic redox potential. It is likely that renal gluconeogenesis is also inhibited and this is reflected by the rise in the concentration of malate in the kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Lactic acidosis and the cardiovascular system in the dog

1. Lactic acidosis is a clinical syndrome characterized by metabolic acidaemia (pH less than 7.25) and hyperlactaemia (lactate greater than 5 mmol/l). Many patients with type B lactic acidosis have no evidence of tissue hypoxia or myocardial dysfunction when first evaluated. Although it is considered that cardiac dysfunction is secondary to the systemic effects of lactic acidosis, the reverse may sometimes be true. To evaluate this possibility, studies were carried out in 43 dogs consisting of a control group and three groups which had hyperlactataemia and metabolic acidaemia related to either: (1) phenformin infusion; (2) hepatectomy; (3) lactic acid infusion. Serial studies of cardiac function, as well as measurements of GFR (glomerular filtration rate) and hepatic portal vein (HPV) blood flow, were carried out. 2. In dogs infused with phenformin for 99 min, the arterial pH, lactate, bicarbonate, heart rate and mean blood pressure (BP) were normal. However, there was significant deterioration (P less than 0.01) in several indices of cardiac function, including the peak positive dP/dt, cardiac output, LVEDP (left ventricular end-diastolic pressure) and percentage extraction of oxygen and lactate by the heart. After 3 h of phenformin, the blood lactate exceeded 5 mmol/l and there were further significant decrements (P less than 0.01) in cardiac output, LVEDP and dP/dt, as well as BP and heart rate. In dogs subjected to hepatectomy, the decrement in cardiac output was similar to that with phenformin infusion. However, in animals infused with lactic acid, despite a similar blood pH and lactate, cardiac output was unaffected. Although percentage myocardial oxygen extraction declined in phenformin-infused animals, there was a concomitant increase in coronary sinus blood flow such that myocardial oxygen utilization was probably unaltered. 3. Thus, in certain types of experimental type B lactic acidosis, myocardial dysfunction may be a primary event, with other associated systemic manifestations being secondary.

Treatment of lactic acidosis with dichloroacetate in dogs

Lactic acidosis is a clinical condition due to accumulation of H(+) ions from lactic acid, characterized by blood lactate levels >5 mM and arterial pH <7.25. In addition to supportive care, treatment usually consists of intravenous NaHCO(3), with a resultant mortality >60%. Dichloroacetate (DCA) is a compound that lowers blood lactate levels under various conditions in both man and laboratory animals. It acts to increase pyruvate oxidation by activation of pyruvate dehydrogenase. We evaluated the effects of DCA in the treatment of two different models of type B experimental lactic acidosis in diabetic dogs: hepatectomy-lactic acidosis and phenformin-lactic acidosis. The metabolic and systemic effects examined included arterial blood pH and levels of bicarbonate and lactate; the intracellular pH (pHi) in liver and skeletal muscle; cardiac index, arterial blood pressure and liver blood flow; liver lactate uptake and extrahepatic splanchnic (gut) lactate production; and mortality. Effects of DCA were compared with those of either NaCl or NaHCO(3). The infusion of DCA and NaHCO(3), delivered equal amounts of volume and sodium, although the quantity of NaHCO(3) infused (2.5 meq/kg per h) was insufficient to normalize arterial pH. In phenformin-lactic acidosis, DCA-treated animals had a mortality of 22%, vs. 89% in those treated with NaHCO(3). DCA therapy increased arterial pH and bicarbonate, liver pHi and cardiac index, with increased liver lactate uptake and a fall in blood lactate. With NaHCO(3) therapy, there were decrements of cardiac index and liver pHi, with an increase in venous pCO(2) and gut production of lactate. Dogs with hepatectomy-lactic acidosis were either treated or pretreated with DCA. Treatment with DCA resulted in stabilization of cardiac index, a fall in blood lactate, and 17% mortality. NaHCO(3) was associated with a continuous decline of cardiac index, rise in blood lactate, and 67% mortality. In dogs pretreated with NaCl, mortality was 33%, but all dogs pretreated with DCA survived. Dogs pretreated with DCA also had lower blood lactate and higher arterial pH and bicarbonate than did those pretreated with NaCl.Thus, in either of two models of type B experimental lactic acidosis, treatment with DCA improves cardiac index, arterial pH, bicarbonate and lactate, and liver pHi. The mortality in dogs with type B lactic acidosis was significantly less in DCA-treated animals than in those treated with other modalities.

[Cure of experimental hyperlactatemia and lactic acidosis by sodium dichloroacetate]

Sodium dichloroacetate prevents and fights against the severe hyperlactatemia and lactic acidosis induced by phenformin, intense muscular work, hypoxia and by adrenalin perfusion. The beneficent effects of sodium dichloroacetate and insulin are additive.

Insulin therapy in phenformin-associated lactic acidosis; a case report, biochemical considerations and review of the literature

A patient with phenformin-associated lactic acidosis was treated with insulin and showed marked improvement coincident with the expected onset of action of the insulin administered. Relative insulin deficiency was demonstrated although several phenomena characteristic of phenformin-associated lactic acidosis obscured its reflection in the usual indices. From data presented and a review of the literature the following pathogenesis is proposed for the observed metabolic derangement. A background of relative insulin deficiency would permit enhanced pyruvate (and hence lactate) formation from protein sources. Insulin deficiency would also lead to inhibition of pyruvate dehydrogenase which slows pyruvate removal. Phenformin accumulation (cf impaired renal function) further reduces pyruvate removal by decreasing its conversion to glucose, but in addition alters the redox state. For the lactic acidosis which results, insulin administration may thus constitute specific therapy. Diabetes 24:28-35, January, 1975.

Calcium-like action of phenethylbiguanide and related compounds: inhibition of pyruvate kinase

Pyruvate kinase (EC 2.7.1.40) is inhibited by phenethylbiguanide. The kinetics of inhibition are competitive between biguanide and divalent, but not monovalent, metal cation activators of the enzyme; biguanide inhibition thus resembles inhibition by Ca(++). Alteration of either the polar or nonpolar portion of the phenethylbiguanide molecule quantitatively reduces its effectiveness as an inhibitor of pyruvate kinase, but the kinetics of inhibition remain qualitatively unchanged. Measurements of [(3)H]phenethylbiguanide binding to the enzyme indicate the presence of a single class of about 12 binding sites per enzyme molecule; binding characteristics are not significantly different in the presence of either monovalent or divalent metal cations. Studies with (45)Ca(++) and (54)Mn(++) demonstrate about 4 metal binding sites per enzyme molecule; phenethylbiguanide displaces these metal cations from the enzyme. Studies with several enzymes, dependent upon divalent metal cations, of both metal-bridge and substrate-bridge classes fail to show significant inhibition except at much higher phenethylbiguanide concentrations.

THE CLINICAL SIGNIFICANCE OF ELEVATED BLOOD LACTATE

Three patients with elevated blood lactate values are described. The first, despite moderate hyperlactatemia of 5.3 mEq./1. and severe acidosis with an arterial blood pH of 6.98, had no "excess lactate". In a second patient, moderate acidosis with a pH of 7.27 and blood lactate of 7.5 mEq./1., of which 33% was excess lactate, was found to be secondary to tissue hypoxia on an ischemic basis and preceded the onset of clinical shock by four hours. A third patient, diabetic and under treatment with phenformin hydrochloride, presented with many features suggestive of pulmonary embolism, including marked pulmonary hypertension. A diagnosis of idiopathic lactic acidosis was established when the arterial blood pH was found to be 6.77 and a blood lactate value of 14.2 mEq./1., 60% as excess lactate, was discovered in the absence of a demonstrable cause of tissue hypoxia. Exploration of the pulmonary vascular bed showed no sign of mechanical blockage. The diagnostic, therapeutic and prognostic value of measuring blood lactic acid, and of quantitating the proportion circulating as "excess lactate", is emphasized.

A SURVEY OF CURRENT THERAPY OF DIABETES MELLITUS

A questionnaire was sent to 2,000 members of the American Diabetes Association during June-September, 1962. It concerned the aims and methods of present day therapy of diabetes mellitus, with special emphasis on therapy with oral agents. The answers were analyzed with respect to size of practice as well as other features. A total of 405 replies were received, comprising about 20,000 patients treated per year.

Six years after the introduction of oral drugs into the United States, 30 per cent of diabetic patients are being treated with such agents. The aims of therapy are not altered from those for insulin treated patients.

There is a noticeable lag in recourse to therapy with a combination of phenformin and a sulfonylurea drug after failure with a single drug. The advantage of use of such combinations in preserving the efficacy of oral therapy is pointed out.

No significant incidence of toxicity or effect upon diabetic complications of these drugs alone or in combination is reported.