Institute of Intensive Care, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
Medical Faculty, University of Basel, Basel, Switzerland.
AIDS Res Ther. 2021 Sep 4;18(1):56. doi: 10.1186/s12981-021-00382-8.
We report a case of sudden, lethal metabolic acidosis in a 70-year-old man on long-term nucleoside reverse transcriptase inhibitor (NRTI) -based antiretroviral therapy (ART) who had developed atypical necrotizing fasciitis 1 month after kidney transplantation.
The HIV infection of the patient was treated for the last four months with an integrase strand inhibitor (dolutegravir 50 mg/d) plus a NRTI backbone including lamivudine (150 mg/d) and abacavir (600 mg/d). In this renal transplant patient we hypothesize that the co-existence of sepsis, renal failure and an accumulation of lamivudine led to the development of fatal metabolic acidosis and hyperlactatemia. Although lamivudine is only rarely associated with hyperlactatemia, there is evidence that overdose may be a risk factor for developing it. In our patient the lamivudine concentration two days after stopping and during hemodiafiltration was more than 50 times higher than therapeutic target trough concentrations. Likely reasons for this were renal impairment and concurrent treatment with trimethoprim, known to inhibit the renal elimination of lamivudine.
NRTIs could trigger the development of hyperlactatemia in septic patients. The use of NRTI sparing regimens might be considered in the presence of this critical condition.
我们报告了一例 70 岁男性长期接受核苷逆转录酶抑制剂（NRTI）为基础的抗逆转录病毒治疗（ART）后出现突发性致命代谢性酸中毒的病例，该患者在肾移植后 1 个月发生了非典型坏死性筋膜炎。
该患者的 HIV 感染在过去四个月中使用整合酶抑制剂（多替拉韦 50mg/d）联合 NRTI 骨干（拉米夫定 150mg/d 和阿巴卡韦 600mg/d）进行治疗。在这位肾移植患者中，我们假设合并脓毒症、肾衰竭和拉米夫定积累导致了致命性代谢性酸中毒和高乳酸血症的发生。尽管拉米夫定很少与高乳酸血症相关，但有证据表明过量可能是其发生的一个危险因素。在我们的患者中，停药后两天和血液透析滤过期间的拉米夫定浓度超过治疗目标谷浓度 50 倍以上。可能的原因是肾功能损害和同时使用已知抑制拉米夫定肾脏清除的甲氧苄啶。
NRTIs 可能会在脓毒症患者中引发高乳酸血症。在存在这种危急情况时，可能需要考虑使用 NRTI 节约方案。
