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Sodium Bicarbonate And Metformin

The Nephrologist's Role In Metformin-induced Lactic Acidosis

The Nephrologist's Role In Metformin-induced Lactic Acidosis

Nefrologia (English Version) 2011;31:587-90 | doi: 10.3265/Nefrologia.pre2011.Jun.10955 The nephrologist's role in metformin-induced lactic acidosis Papel del nefrlogo en la acidosis lctica grave por metformina a Secci??n de Nefrolog??a, Hospital Universitario de Guadalajara, Guadalajara, Spain, b Secci??n de Nefrolog??a, Hospital Universitario de Guadalajara, c Secci??n de Nefrolog??a, Hospital Universitario de Guadalajara. Departamento de Medicina. Universidad de Alcal??, Tab. 1. Clinical and analytical data, and treatment received by patients La metformina es un frmaco ampliamente utilizado en sujetos con diabetes mellitus y su eficacia para descender la glucemia y la hemoglobinaA1C(HbA1C) es notable. Sin embargo, en algunos pacientes, sobre todo en los que presentancomorbilidades, puede provocar una acidosis lctica grave que origina una elevada morbimortalidad. El tratamiento de esta complicacin se basa en la utilizacin de medidas de soporte y, en los casos ms graves, en procedimientos de depuracin extrarrenal, como la hemodilisis o la hemodiafiltracin continua. Metformin is an antihyperglycemic agent commonly used in diabetic patients. It is very effective and is able to reduce the plasma glucose and HbA1C. However, in some patients, specially those with comorbidities, metformin can provoke severe lactic acidosis with high morbimortality. Treatment of the lactic acidosis induced by metformin is based on the use of supportive general measures; in severe cases, procedures of extrarrenal purification like hemodialysis or continuous hemodiafiltration have been successfully used. Metformin is the main biguanide, widely used in diabetes mellitus treatment.1 It is a glycaemia-lowering agent that promotes glucose entering the tissues and reduces hepatic gluconeogenesis an Continue reading >>

Diabetes & Sodium Bicarbonate

Diabetes & Sodium Bicarbonate

Diabetics who poorly manage their disease might develop a life-threatening condition called diabetic ketoacidosis, which is characterized by nausea or vomiting, dry mouth, fruity breath, deep rapid breathing and abdominal pain. Diabetic ketoacidosis occurs when fat and protein is used as the body’s main energy source. As a result, ketones, which are poisonous in large quantities, accumulate and acidify body fluids, which can be neutralized by sodium bicarbonate therapy. Sodium bicarbonate is available in various forms, such as solutions, powders, tablets, capsules and granules. Video of the Day Diabetes affected 25.6 million Americans 20 years of age and older in 2010, accordng to the National Diabetes Information Clearinghouse. There are two main types of diabetics: insulin resistant, or type 2 diabetics; and insulin dependent, or type 1 diabetics. Insulin-resistant diabetics produce insulin but do not respond to it. Insulin-dependent diabetics do not produce insulin and must self-administer the hormone via an insulin pump or daily injections. Diabetes, which was previously regarded as an adulthood disease, has been increasingly diagnosed in children and adolescents. According to the Centers for Disease Control and Prevention, most children diagnosed with type 2 diabetes are 10 to 19 years of age, obese, have a family history of type 2 diabetes and exhibit insulin resistance. Diabetic Ketoacidosis Onset Diabetics are prone to ketoacidosis because of carbohydrate restrictions and the body’s inability to metabolize glucose. Carbohydrates, which the body converts to glucose, serve as the body’s main energy source; however, in its absence, the body initiates lipolysis and proteolysis, or fat and protein metabolism. As a result of these two mechanisms, the liver relea Continue reading >>

Lactic Acidosis Secondary To Metformin Overdose: A Case Report

Lactic Acidosis Secondary To Metformin Overdose: A Case Report

Lactic acidosis secondary to metformin overdose: a case report We are experimenting with display styles that make it easier to read articles in PMC. The ePub format uses eBook readers, which have several "ease of reading" features already built in. The ePub format is best viewed in the iBooks reader. You may notice problems with the display of certain parts of an article in other eReaders. Generating an ePub file may take a long time, please be patient. Lactic acidosis secondary to metformin overdose: a case report Simon Timbrell, Gary Wilbourn, [...], and Alan Liddle Metformin is a commonly used treatment modality in type 2 diabetes mellitus, with a well documented side effect of lactic acidosis. In the intensive care setting lactate and pH levels are regularly used as a useful predictor of poor prognosis. In this article we highlight how high lactate levels are not an accurate predictor of mortality in deliberate metformin overdose. We present the case of a 70-year-old Caucasian man who took a deliberate metformin overdose of unknown quantity. He had a profound lactic acidosis at presentation with a pH of 6.93 and a lactate level of more than 20mmol/L. These figures would normally correspond with a mortality of more than 80%; however, with appropriate management this patients condition improved. We provide evidence that the decision to treat severe lactic acidosis in deliberate metformin overdose should not be based on arterial lactate and pH levels, as would be the case in other overdoses. We also demonstrate that appropriate treatment with hemodiafiltration and 8.4% sodium bicarbonate, even in patients with a very high lactate and low pH, can be successful. Metformin is a biguanide typically used as a first line drug for the treatment of type 2 diabetes mellitus. I Continue reading >>

Sodium Bicarbonate - Side Effects, Dosage, Interactions - Drugs

Sodium Bicarbonate - Side Effects, Dosage, Interactions - Drugs

Sodium bicarbonate is the generic name for a drug that is most commonly used to calm upset stomach caused by irritation from acid reflux . It's available in tablet form and is also sold in combination with omeprazole ( Prilosec ) as the over-the-counter (OTC) drug Zegerid for acid reflux. Sodium bicarbonate belongs to a class of drugs called antacids . An injectable form of sodium bicarbonate is also given by healthcare practitioners to help improve the acid-base balance of the body when it becomes too acidic, which happens in severe cases of diabetes, shock, kidney failure, dehydration, and a condition known as lactic acidosis. If you have any of the following conditions, tell your doctor, who may advise you not to take sodium bicarbonate or to watch for certain types of reactions. Allergies to sodium bicarbonate or any other ingredients of the medication If you have abnormal levels of sodium, potassium, calcium, or chlorine, your doctor may advise you not to take sodium bicarbonate, or to least monitor levels of your electrolytes closely. Before taking sodium bicarbonate, tell your doctor if you are on a low-sodium diet or if you have a rare kidney disorder known as Bartter syndrome, because it causes potassium, sodium, and chloride levels to be out of balance. If your body's pH is higher than normal (known as alkalosis), you should not take sodium bicarbonate. People taking sodium bicarbonate should try not to consume large amounts of high calcium-containing foods (such as milk, cheese, or yogurt) and should not take calcium supplements. Sodium bicarbonate falls under the FDA's Pregnancy Category C, which means that it should be avoided because we don't know if it will harm to an unborn baby or fetus. You should tell your doctor if you are pregnant or plan to become Continue reading >>

Lactic Acidosis Treatment & Management: Approach Considerations, Sodium Bicarbonate, Tromethamine

Lactic Acidosis Treatment & Management: Approach Considerations, Sodium Bicarbonate, Tromethamine

Author: Kyle J Gunnerson, MD; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM more... Treatment is directed towards correcting the underlying cause of lactic acidosis and optimizing tissue oxygen delivery. The former is addressed by various therapies, including administration of appropriate antibiotics, surgical drainage and debridement of a septic focus, chemotherapy of malignant disorders, discontinuation of causative drugs, and dietary modification in certain types of congenital lactate acidosis. Cardiovascular collapse secondary to hypovolemia or sepsis should be treated with fluid replacement. Both crystalloids and colloids can restore intravascular volume, but hydroxyethyl starch solutions should be avoided owing to increased mortality. [ 21 ] Excessive normal saline administration can cause a nongap metabolic acidosis due to hyperchloremia, which has been associated with increased acute kidney injury. [ 32 ] Balanced salt solutions such as Ringer lactate and Plasma-Lyte will not cause a nongap metabolic acidosis and may reduce the need for renal replacement therapy; however, these can cause a metabolic alkalosis. [ 33 ] No randomized, controlled trial has yet established the safest and most effective crystalloid. If a colloid is indicated, albumin should be used. Despite appropriate fluid management, vasopressors or inotropes may still be required to augment oxygen delivery. Acidemia decreases the response to catecholamines, and higher doses may be needed. Conversely, high doses may exacerbate ischemia in critical tissue beds. Careful dose titration is needed to maximize benefit and reduce harm. Lactic acidosis causes a compensatory increase in minute ventilation. Patients may be tachypneic initially, but respiratory muscle fatigue can ensue rapidly a Continue reading >>

Publications

Publications

A 14-year-old girl has taken 45 gr ( 0.75 g kg-1 body weight) of metformin in a suicide attempt. The first arterial blood gas showed a marked metobolic acidosis with a high lactat level and subsequently she developed moderate renal failure. The lactic acidosis was successfully treated with early continuous venovenous hemodiafiltration. After 16 h of haemofiltration, the arterial pH steadily increased back to normal levels, and lactic acidosis improved. It is concluded that patients with severe lactic acidosis secondary to metformin overdose should be treated promptly with hemofiltration. Introduction Metformin is a biguanide class drug. Biguanides have been used for many years as oral anti-hyperglycemic agents in the treatment of type II diabetes mellitus. These agents exert their action by increasing cellular insulin sensitivity. Lactic acidosis is a rare but serious adverse effect of metformin, especially in patients with renal failure. Severe lactic acidosis is a recognised and often fatal complication of metformin overdose. Metformin is absorbed relatively rapidly by the intestine and is not metabolised. Abouth 90% of the drug is eleminated by glomerular filtration and tubular secretion with a serum half-life between 1,5 and 5 hours. There are several case reports of metformin overdose in the literature but intoxications with metformine in childhood are rare. In this report we describe a 14 year old healthy girl who devoloped lactic acidosis after ingestion of a metformin overdose. The 14-year-old girl took 45 gr ( 0.75 gr kg-1 body weight) of metformin in a suicide attempt. When she was admitted to the emergency department, she had a Glasgow Coma Scale Score of 13-15. Her body temperature was 36.2 0C. Arteriel pressure was 110/60 mmHg, heart rate 77 beats min-1, re Continue reading >>

The Role Of Sodium Bicarbonate In The Management Of Some Toxic Ingestions

The Role Of Sodium Bicarbonate In The Management Of Some Toxic Ingestions

The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions 1Department of Medicine, University of Kentucky College of Medicine, Lexington, KY, USA 2University of Kansas Medical Center, Kansas City, KS, USA Correspondence should be addressed to Aibek E. Mirrakhimov ; [email protected] Received 2 March 2017; Revised 2 June 2017; Accepted 11 July 2017; Published 8 August 2017 Copyright 2017 Aibek E. Mirrakhimov et al. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. In this article, we review the data regarding the impact of systemic sodium bicarbonate administration in the management of certain poisonings including sodium channel blocker toxicities, salicylate overdose, and ingestion of some toxic alcohols and in various pharmacological toxicities. Based on the available literature and empiric experience, the administration of sodium bicarbonate appears to be beneficial in the management of a patient with the above-mentioned toxidromes. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. The potential mechanisms of sodium bicarbonate include high sodium load and the development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance with subsequent increased urinary excretion. W Continue reading >>

Ph 6.68surviving Severe Metformin Intoxication

Ph 6.68surviving Severe Metformin Intoxication

Metformin, a widely used anti-diabetic agent of the biguanide family, although generally safe, 1 , 2 , 3 , 4 holds the risk of developing a potentially lethal acidosis. 5 , 6 The association between lactic acidosis and metformin is well-established but rarely seen in patients taking this medication. 7 Its elimination relies solely on kidneys excretion, 8 so its accumulation is feasible in just two circumstances: renal failure (RF) and acute overdosage. At normal dosage, a toxic accumulation of drug requires time after the development of RF, due to metformin high clearance. About 90% of the drug is eliminated by glomerular filtration and tubular secretion (serum half-life of 1.55 h). Moreover, RF is itself associated with acidosis as it impairs kidneys ability to excrete protons. Acute intoxication on the other hand is a viable option in those cases where renal function is normal and can correlate with a psychiatric disorder. The mechanism thought to be responsible for lactic acidosis is suppression of gluconeogenesis forming lactate, pyruvate, glycerol and amino acids leading to lactate accumulation, 9 a risk that is increased by either chronic or acute RF (ARF). Usually hyperlactatemia is the most common finding leaving lactic acidosis for the most severe intoxications. A 47-year-old, apparently previously fit, non-insulin-dependent diabetic male was brought to the Emergency Department for hypoglycemia, agitation and hyperventilation. Ambulance crew found blood glucose level at 1.33 mmol/l (24 mg/dl) and administered 20 ml of 33% glucose solution followed by other 250 ml at 5%. At the arrival in the Emergency Room, the patient was confused and agitated with no signs of respiratory distress or shock. Arterial blood gases (ABG) and laboratory tests are summarized in Tab Continue reading >>

Diabetes - Acid Conditions And Treatment With Sodium Bicarbonate

Diabetes - Acid Conditions And Treatment With Sodium Bicarbonate

A highly acidic pH level (created by all the above) puts the pancreas, liver, and all the bodys organs at risk. Because of the important role played by the liver in removing acid waste from the body, liver function is particularly at risk when acids accumulate. When acidity prevents the liver and pancreas from regulating blood sugar, the risk of diabetes will increase. We already know that sodium bicarbonate dramatically slows the progress of chronic kidney disease but few have followed the logical conclusion that it would also be a front line defense against diabetes. From prevention to treatment and to part of a cure, common Baking Soda is an essential tool in working with diabetic and metabolic syndromes. Obviously it does not take the place of an alkaline diet and water but bicarbonate is a front line medicine that doctors and patients can employ orally and transdermally in baths. Sodium bicarbonate injections are already indicated in the treatment of metabolic acidosis, which may occur in severe renal disease, uncontrolled diabetes, and circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis. But sodium bicarbonate can be used safely at home orally and transdermally (and should always be used with magnesium chloride for greatest effect) in all stages of diabetes. Low grade chronic metabolic acidosis exists normally in humans eating ordinary diets, and that the degree of acidosis increases with age. Dr Lynda Frassetto According to Dr Lynda Frassetto, an acid alkaline researcher from the University of California, We have been forced to turn an evolutionary corner. Our bodies are so overwhelmed with cellular acid-wastethat We simply do not handle acid waste the way we used to Continue reading >>

Treatment Of Metformin-associated Lactic Acidosis With Closed Recirculation Bicarbonate-buffered Hemodialysis

Treatment Of Metformin-associated Lactic Acidosis With Closed Recirculation Bicarbonate-buffered Hemodialysis

Treatment of Metformin-Associated Lactic Acidosis With Closed Recirculation Bicarbonate-Buffered Hemodialysis To the Editor. The use of massive amounts of intravenous (IV) sodium bicarbonate in the management of lactic acidosis seems necessary as soon as the acidosis becomes severe.1 However, some patients have an apparent resistance to this alkali therapy.2 In addition, intensive administration of sodium bicarbonate carries the combined risks of volume and sodium overload. Several authors tried hemodialysis (HD) or peritoneal dialysis (PD) but, most of the time, the precarious hemodynamic state of these patients limits the use of conventional HD.3,4 The new possibilities allowing the use of dialysate containing bicarbonate in HD have led us to try this method in the case of a metformin-treated diabetic with severe lactic acidosis.5 Report of a Case. A 64-year-old woman was admitted to the hospital in severe shock. Despite chronic renal failure (serum creatinine level of 300 moles/L, she was given 1,700 mg/day of metformin for six Continue reading >>

Prime Pubmed | Lacticemia After Acute Overdose Of Metformin In An Adolescent Managed Without Intravenous Sodium Bicarbonate Or Extracorporeal Therap

Prime Pubmed | Lacticemia After Acute Overdose Of Metformin In An Adolescent Managed Without Intravenous Sodium Bicarbonate Or Extracorporeal Therap

Type your tag names separated by a space and hit enter Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Metformin-associated lactic acidosis or lacticemia has been widely reported as an adverse drug effect in diabetic patients with other significant comorbidities and in acute overdose in adults. Lacticemia has been reported twice in a previously healthy pediatric population, both of which were suicide attempts and required hemodialysis. We report a case of a 17-year-old, nondiabetic, healthy adolescent girl with metformin-associated lacticemia who intentionally overdosed on metformin, had no coingestants, and was treated only with crystalloids. Furthermore, she did not require intravenous bicarbonate administration or extracorporeal removal. Bebarta VS, Pead J, Varney SM: "Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy." Pediatric emergency care, vol. 31, no. 8, 2015, pp. 589-90, Accessed September 26, 2018. Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care 2015;31(8):589-90 Accessed September 26, 2018. Bebarta VS & Pead J & Varney SM. (2015). Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatric emergency care, 31, pp. 589-90. doi:10.1097/PEC.0000000000000517 Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care. 2015;31:589-90 TY - JOURT1 - L Continue reading >>

Sodium Bicarbonate Drug Interactions

Sodium Bicarbonate Drug Interactions

A total of 372 drugs (3167 brand and generic names) are known to interact with sodium bicarbonate . 5 major drug interactions (19 brand and generic names) 279 moderate drug interactions (2692 brand and generic names) 88 minor drug interactions (456 brand and generic names) Show all medications in the database that may interact with sodium bicarbonate. Check for interactions with sodium bicarbonate Type in a drug name and select a drug from the list. The classifications below are a general guideline only. It is difficult to determine the relevance of a particular drug interaction to any individual given the large number of variables. Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit. Moderately clinically significant. Usually avoid combinations; use it only under special circumstances. Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan. Do not stop taking any medications without consulting your healthcare provider. Disclaimer: Every effort has been made to ensure that the information provided by Multum is accurate, up-to-date and complete, but no guarantee is made to that effect. In addition, the drug information contained herein may be time sensitive and should not be utilized as a reference resource beyond the date hereof. This material does not endorse drugs, diagnose patients, or recommend therapy. Multum's information is a reference resource designed as supplement to, and not a substitute for, the expertise, skill, knowledge, and judgement of healthcare practitioners in patient care. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate tha Continue reading >>

Baking Soda - The Nightmare Of The Pharmaceutical Industry

Baking Soda - The Nightmare Of The Pharmaceutical Industry

Baking Soda The Nightmare of the Pharmaceutical Industry According to the result of research findings, cancer is a lactic acid, which is formed when a certain kind of fungus or moldlives in an environment devoid of oxygen. It was also discovered that by passing a very high concentration of oxygen molecules through cancer cells, it could destroy them completely. It is really very difficult for anyone to wrap their head around the idea that a substance as common as sodium bicarbonate (baking soda) can offer much more benefits than most of the pharmaceutical drugs that cost so much. There is however fascinating evidence that proves that sodium bicarbonate can indeed cure a lot of serious diseases, such as cancer and diabetes. Medical practitioners have also been advised to use it since it offers amazing benefits. Sodium bicarbonate, it must be noted, is a very widely researched substance, which has been used for several years even by oncologists. The toxicity of chemotherapy and radiation are such that could destroy vital organs of the body, like the liver and kidneys, therefore, sodium bicarbonate is usually given periodically to patients to prevent this possibility. All over the world, multitudes add sodium bicarbonate to their drinking water with the intention of curingclinical acidosis and other adverse conditions. It isa well known fact that sodium bicarbonate has saved a lot of lives in the emergengy rooms. The combination of baking soda with other natural substances like iodine and magnesium chloride produces a mixture that is a wonder in the medical world. A major issue with regards tohuman physiology is the problem of a lack of bicarbonate ions. This results in a decrease in the pH value of the blood. Enzymes are a fundamental part of biochemical reactions and th Continue reading >>

Metformin Poisoning: A Complex Presentation

Metformin Poisoning: A Complex Presentation

Metformin poisoning: A complex presentation We are experimenting with display styles that make it easier to read articles in PMC. The ePub format uses eBook readers, which have several "ease of reading" features already built in. The ePub format is best viewed in the iBooks reader. You may notice problems with the display of certain parts of an article in other eReaders. Generating an ePub file may take a long time, please be patient. Metformin poisoning: A complex presentation Manish Jagia, Salah Taqi, and Mahmud Hanafi The objective of this case report is to highlight presentation, complications and treatment of metformin poisoning. Patient after ingestion of 45gms of metformin developed colicky abdominal pain, severe tachypnea and vomiting. He developed severe lactic acidosis, cardiac arrest, pancreatitis and hemolytic anemia which was treated with charcoal, sodium bicarbonate, early initiation of high volume continuous veno-venous hemofiltration and supportive therapy. Metformin poisoning is a rare presentation and we discuss course of events in the management of metformin poisoning and its associated complications. Keywords: Cardiac arrest, haemolytic anemia, lactic acidosis, metformin poisoning, pancreatitis Metformin is a biguanide oral hypoglycemic agent used for non-insulin dependent diabetes mellitus (NIDDM). Metformin poisoning can cause fatal complications like severe lactic acidosis, haemolytic anemia and pancreatitis. Early diagnosis can result in successful outcome. Here, we report a case having good recovery despite metformin induced complications and cardiac arrest. A 36-year-old man presented in the Emergency Department after ingestion of 45 g metformin. He presented with colicky abdominal pain, severe tachypnoea and vomiting. He had history of NIDDM Continue reading >>

Metformin-related Lactic Acidosis: Case Report - Sciencedirect

Metformin-related Lactic Acidosis: Case Report - Sciencedirect

Open Access funded by Sociedad Colombiana de Anestesiologa y Reanimacin Lactic acidosis is defined as the presence of pH <7.35, blood lactate >2.0mmol/L and PaCO2 <42mmHg. However, the definition of severe lactic acidosis is controversial. The primary cause of severe lactic acidosis is shock. Although rare, metformin-related lactic acidosis is associated with a mortality as high as 50%. The treatment for metabolic acidosis, including lactic acidosis, may be specific or general, using sodium bicarbonate, trihydroxyaminomethane, carbicarb or continuous haemodiafiltration. The successful treatment of lactic acidosis depends on the control of the aetiological source. Intermittent or continuous renal replacement therapy is perfectly justified, shock being the argument for deciding which modality to use. We report a case of a male patient presenting with metformin poisoning as a result of attempted suicide, who developed lactic acidosis and multiple organ failure. The critical success factor was treatment with continuous haemodiafiltration. Definimos acidosis lctica en presencia de pH <7.35, lactato en sangre >2.0mmol/L y PaCO2 <42mmHg. Por otro lado, la definicin de acidosis lctica grave es controvertida. La causa principal de acidosis lctica grave es el estado de choque. La acidosis lctica por metformina es rara pero alcanza mortalidad del 50%. La acidosis metablica incluyendo a la acidosis lctica puede recibir tratamiento especfico o tratamiento general con bicarbonato de sodio, trihidroxiaminometano, carbicarb o hemodiafiltracin continua. El xito del tratamiento de la acidosis lctica yace en el control de la fuente etiolgica; la terapia de reemplazo renal intermitente o continua est perfectamente justificada, donde el argumento para decidir cul utilizar ser el estado de Continue reading >>

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