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General Recommendation

  • ECTR is recommended in severe metformin poisoning (1D)



ECTR is indicated if ANY of the following conditions are present:

  • Lactate concentration > 20 mmol/L (recommendation, 1D), > 15 mmol/L (suggestion, 2D)

  • pH ≤ 7.0 (recommendation 1D), pH  7.1 (suggestion, 2D)

  • Failure of standard supportive measures (1D)

  • Comorbid contions that lower the threshold for ECTR initiation

    • Shock (1D)​

    • Impaired kidney function (1D)

    • Liver failure (2D)

    • Decreased level of consciousness (2D)


Cessation of ECTR is indicated when

  • Lactate concentration < 3 mmol/L (1D)  


  • pH > 7.35 (1D)

Choice of ECTR

  • Intermittent hemodialysis (with bicarbonate buffer) is preferred initially (1D)

  • Continuous kidney replacement therapies may be considered if hemodialysis is unavailable (2D)

  • Repeat extracorporeal treatment sessions may use hemodialysis (1D) or continuous kidney replacement therapy (1D).​


  • Close monitoring of lactate and acid-base status is warranted after ECTR to determine the need for additional courses of extracorporeal treatment. 

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