Thursday, July 1, 2010

Topic Discussion: D-Lactate vs D-lactic acid

Do we ever wonder when we give lactate ringers and use lactate in our PD fluids.. what happens to that? Lactate comes in 2 forms the D- and L+ isomers and LR contains both of them.  Humans lack D lactate dehydrogenase. Its only 10% of what we can do with L lactate.  This ultimately gets metabolized to base and as a result we can use it as an effective medium for PD as well. The PD fluid is both a mix of D and L lacatate. 
This keeps the sugar from carmelizing.  When you give someone LR or lactate, do you get lactic acidosis-D?
Well lactate is a base and not the acid so it should not and hence we don't see it causing it. LR is a widely used fluid and lactate in PD fluid is also widely used. Accumulation of D lactic acid will cause an anion gap if that would happen. The lactate( base ) is not usually associated with this problem.

Where do you see D lactic acidosis?  It can occur in patients with jejunoileal bypass or, less commonly, small bowel resection or other cause of the short bowel syndrome. This is due to overgrowth of gram positive anerobes and relatively low glucose delivery to the colon.

Think of this diagnosis when there is elevated anion gap, normal lactate, negative ketones, considered in the patient presenting with an increased serum anion gap, normal serum concentrations of lactate, negative ketones, and history of short gut syndrome or bypass as stated above.  

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