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Background: Metformin-associated lactic acidosis (MALA) is a severe complication of drug administration with significant morbidity and mortality. So far no study in large population areas have examined the incidence, clinical profile and outcome of acute kidney injury (AKI)-MALA patients admitted in intensive care units (ICUs) and treated by renal replacement therapy (MALA-RRT). Methods: Retrospective analysis over a 6-year period (2010-2015) in Piedmont and Aosta Valley regions (5,305,940 inhabitants, 141,174 diabetics treated with metformin) of all MALA-RRT cases. Results: One hundred and seventeen cases of AKI-MALA-RRT were observed (12.04/100,000 metformin treated diabetics, 1.45% of all RRT-ICU patients). Survival rate was 78.3%. The average duration of RRT was 4.0 days at mean dialysis effluent of 977 mL/kg/day. At admission most patients were dehydrated, and experienced shock and oliguria. Conclusion: Our data showed that MALA-RRT is a common complication, needing more prevention. Adopted policy of early, extended, continuous and high efficiency dialysis could contribute to an observed high survival rate. Video Journal Club “Cappuccino with Claudio Ronco” at http://www.karger.com/?doi=471917.

To the Editor: The excellent paper by De Vriese et al in a recent issue of Kidney International on folate for cardiovascular disease in uremia largely underestimates the risk of folate overdose1. The suggestion that "high doses of folic acid are well tolerated and safe" takes root from four studies with 4 to 8 weeks and 12 to 17 months of follow-up. From one 10-year-old reference is the message that "routine measurement of vitamin B12 concentrations and inclusion of vitamin B12 in the supplements should completely eliminate ... the risk of masking vitamin B12 deficiency." Because close surveillance is suggested to look for adverse effects produced from folate fortification of food in the general population, which increases serum folate from 10.8 to 19.0 ng/mL2, how can we forecast that in uremic people values as high as 200 to 400 ng/mL are safe over a long time? Treatment for hyperhomocysteinemia in uremic patients results in normal vitamin B12 coupled with very high folate concentrations (Fig. 1). Could such an unbalance derange the biochemical basis of folate/vitamin B12 interrelationship producing a "relative" vitamin B12 deficiency?