ÂÑÁ×ÅÉÁ ÁÍÁÓÊÏÐÇÓÇ
ÁÑ×ÅÉÁ ÅËËÇÍÉÊÇÓ ÉÁÔÑÉÊÇÓ 2001, 18(5):451–456
BRIEF REVIEW
ÃáëáêôéêÞ ïîÝùóç
ËÝîåéò åõñåôçñßïõ
Ãáëáêôéêü ïîý
ÄéôôáíèñáêéêÜ
ÌåôáâïëéêÞ ïîÝùóç
Ç ãáëáêôéêÞ ïîÝùóç åßíáé ìéá áðü ôéò óõ÷íüôåñåò
ìïñöÝò åíäïíïóïêïìåéáêÞò ìåôáâïëéêÞò ïîÝùóçò óôçí
êáèçìåñéíÞ êëéíéêÞ ðñÜîç. Ç ôá÷åßá õðåñðáñáãùãÞ êáé
Üèñïéóç óôïí åîùêõôôÜñéï ÷þñï ìåãÜëùí ðïóïôÞôùí ãá-
ëáêôéêïý ïîÝïò, ðïõ ôç ÷áñáêôçñßæåé, ç âáñýôçôá ôçò õ-
ðïêåßìåíçò íüóïõ êáé ç ó÷åôéêÞ áíáðïôåëåóìáôéêüôçôá
ôçò èåñáðåßáò êáèéóôïýí ôçí ðñüãíùóÞ ôçò åîáéñåôéêÜ
äõóìåíÞ.
ÂÉÏ×ÇÌÅÉÁ
Ç öõóéïëïãéêÞ êáèçìåñéíÞ ðáñáãùãÞ ãáëáêôéêïý
ïîÝïò áíÝñ÷åôáé óå 15–20 mEq/kg âÜñïõò óþìáôïò,1
ìå êýñéåò ðçãÝò ðñïÝëåõóçò ôïõò ãñáììùôïýò ìõò,
ôá åñõèñÜ áéìïóöáßñéá, ôïí åãêÝöáëï, ôï äÝñìá êáé
ôï ãáóôñåíôåñéêü âëåííïãüíï. 2 Ôï ãáëáêôéêü ïîý ðñï-
Ýñ÷åôáé áðü ôï ìåôáâïëéóìü ôïõ ðõñïóôáöõëéêïý ìå
ôçí êáôáëõôéêÞ äñÜóç ôçò ãáëáêôéêÞò áöõäñïãïíÜóçò
(LDH) êáé ìå ôáõôü÷ñïíç ïîåßäùóç ôïõ NaDH óå
NaD+:
LDH
CH3COCOO–+NaDH+H+«CH3CH(OH)COO–+NaD+ (1)
(ðõñïóôáöõëéêü) (ãáëáêôéêü)
Óýìöùíá ìå ôï íüìï äñÜóçò ôùí ìáæþí, ç óôáèåñÜ
éóïññïðßáò k ôçò ðáñáðÜíù áíôßäñáóçò éóïýôáé ìå:
[ãáëáêôéêü][ÍaD+]
k= (2)
[ðõñïóôáöõëéêü][ÍaDH][H+]
êáé óõíåðþò:
ARCHIVES OF HELLENIC MEDICINE 2001, 18(5):451–456
Ã. ÔóïõöÜêçò
Íåöñïëïãéêü ÔìÞìá,
ÐÃÍÁ «Ã. ÃåííçìáôÜò»
Lactic acidosis
Abstract at the end of the article
ÕðïâëÞèçêå 20.3.2001
Åãêñßèçêå 14.6.2001
[ÍaDH]
[ãáëáêôéêü]=k [ðõñïóôáöõëéêü] [Ç+] (3)
[ÍaD+]
Áðü ôçí åîßóùóç (3) ðñïêýðôåé üôé ç ðáñáãùãÞ ôïõ
ãáëáêôéêïý åîáñôÜôáé áðü 3 ðáñÜãïíôåò: ôç óõãêÝ-
íôñùóç ôïõ ðõñïóôáöõëéêïý, ôï ëüãï ôùí óõãêåíôñþ-
óåùí [NaDH]/[NaD+] (ïîåéäïáíáãùãéêü äõíáìéêü ôïõ
êõôôÜñïõ) êáé ôç óõãêÝíôñùóç Ç+(pH).
Ôï ðõñïóôáöõëéêü ïîý áðïôåëåß åíäéÜìåóï óôáèìü
ðïëëþí ìåôáâïëéêþí ïäþí. Ç êõñéüôåñç ðçãÞ ðáñáãù-
ãÞò ôïõ åßíáé ç ãëõêüæç êáé äåõôåñåõüíôùò ôï áìéíïîý
áëáíßíç. Ç áíáåñüâéá ãëõêüëõóç (ìåôáâïëéêÞ ïäüò Em-
bden-Ìeyerhof) åðéôåëåßôáé óôï êõôôáñüðëáóìá êáé êá-
ôáëÞãåé óôç ìåôáôñïðÞ ôçò ãëõêüæçò óå ðõñïóôáöõëéêü,
ìå ôáõôü÷ñïíç ðáñáãùãÞ NaDH êáé 2 mmol ATP ãéá
êÜèå mmol ÷ñçóéìïðïéïýìåíçò ãëõêüæçò (åéê. 1).
Ç ìåãáëýôåñç ðïóüôçôá ôïõ ðáñáãüìåíïõ ðõñïóôá-
öõëéêïý åéóÝñ÷åôáé óôá ìéôï÷üíäñéá ôïõ êõôôÜñïõ êáé
ìåôáâïëßæåôáé óôïí êýêëï ôùí ôñéêáñâïîõëéêþí ïîÝùí
(êýêëïò Krebs) ðñïò ðáñáãùãÞ CO2, H2O êáé åðéðñü-
óèåôùí 36 mmol ATP/mmol ãëõêüæçò. Óôéò áíôéäñÜóåéò
áõôÝò, ôï ðáñá÷èÝí êáôÜ ôçí áíáåñüâéá ãëõêüëõóç
NaDH ïîåéäþíåôáé óå NaD+ (åéê. 1).
Óå óõíèÞêåò öõóéïëïãéêÞò ïîõãüíùóçò ôïõ êõôôÜñïõ,
ìéêñü ìüíï ìÝñïò ôïõ ðáñáãüìåíïõ ðõñïóôáöõëéêïý
ìåôáôñÝðåôáé óå ãáëáêôéêü ïîý (áíôßäñáóç 1) (åéê. 1),
áëëÜ, óå áðüëõôïõò áñéèìïýò, ç áíùôÝñù äéáäéêáóßá
ïäçãåß óôçí ðáñáãùãÞ, üðùò ðñïáíáöÝñèçêå, 15–20
mEq ãáëáêôéêïý ïîÝïò/kg âÜñïõò óþìáôïò/çìÝñá.
452
Åéêüíá 1. ÁðëïðïéçìÝíç ó÷çìáôéêÞ ðáñÜóôáóç ôçò ãëõêüëõóçò. ÇÊ:
ÅîïêéíÜóç, ÑFK: ÖùóöïöñïõêôïêéíÜóç, ÑÊ: ÐõñïóôáöõëéêÞ êáñâï-
îõëÜóç, PDH: ÐõñïóôáöõëéêÞ áöõäñïãïíÜóç.
Ôï ðáñáãüìåíï áðü ôï ìåôáâïëéóìü ôïõ ðõñïóôá-
öõëéêïý ãáëáêôéêü ïîý ìåôáöÝñåôáé êõñßùò óôï Þðáñ
(50–60%) êáé óôïõò íåöñïýò (30%), üðïõ õößóôáôáé ðå-
ñáéôÝñù ìåôáâïëéóìü.
Óôï Þðáñ, ôï ãáëáêôéêü ïîý åðáíáìåôáôñÝðåôáé óå ðõ-
ñïóôáöõëéêü ìå ôç äñÜóç ôçò LDH. Ôï 80% ôïõ ðá-
ñáãüìåíïõ ðõñïóôáöõëéêïý åéóÝñ÷åôáé óôá ìéôï÷üíäñéá
êáé ìå ôçí êáôáëõôéêÞ äñÜóç ôçò ðõñïóôáöõëéêÞò áöõ-
äñïãïíÜóçò (PDH) ìåôáôñÝðåôáé óå áêåôõëï-CoA êáé
åéóÝñ÷åôáé óôïí êýêëï ôïõ Krebs. Ôï õðüëïéðï ðïóïóôü
êáôáëÞãåé óôçí ðáñáãùãÞ ãëõêüæçò ìå ôï ìç÷áíéóìü
ôçò íåïãëõêïãÝíåóçò (êáôáëõôéêÞ äñÜóç ôçò ðõñïóôá-
öõëéêÞò êáñâïîõëÜóçò, ÑÊ) (åéê. 2).
Ç íåöñéêÞ óõììåôï÷Þ óôï ÷åéñéóìü ôïõ ãáëáêôéêïý åß-
íáé ìéêñüôåñïõ âáèìïý êáé ðåñéëáìâÜíåé ôçí ïîåßäùóç
(êýêëïò Krebs), ôç íåïãëõêïãÝíåóç êáé ôç íåöñéêÞ á-
ðïâïëÞ. Ç ôåëåõôáßá åßíáé ðïëý ðåñéïñéóìÝíç (ìüíï ôï
0,4% ôçò öõóéïëïãéêÞò ðáñáãùãÞò ãáëáêôéêïý áðï-
âÜëëåôáé óôá ïýñá), êõñßùò ëüãù ôçò ìåãÜëçò åðáíáñ-
ñïöçôéêÞò éêáíüôçôáò ôïõ ïõñïöüñïõ óùëçíáñßïõ ãéá
ôá äéçèïýìåíá éüíôá ãáëáêôéêïý.
Ï ìåôáâïëéóìüò ôïõ ãáëáêôéêïý óå ðõñïóôáöõëéêü êáé
ïé ðåñáéôÝñù ìåôáôñïðÝò ôïõ ôåëåõôáßïõ óå CO2+H2O
+ATP (êýêëïò Krebs) êáé ãëõêüæç (êýêëïò Cori) ïäç-
ãïýí óå åðáíáóýíèåóç äéôôáíèñáêéêþí, åíþ ôáõôü÷ñï-
Ã. ÔÓÏÕÖÁÊÇÓ
Åéêüíá 2. ÁðëïðïéçìÝíç ó÷çìáôéêÞ ðáñÜóôáóç ôïõ çðáôéêïý ìåôáâï-
ëéóìïý ôïõ ãáëáêôéêïý ïîÝïò. LDH: ÃáëáêôéêÞ áöõäñïãïíÜóç, ÑÊ: Ðõ-
ñïóôáöõëéêÞ êáñâïîõëÜóç, PDH: ÐõñïóôáöõëéêÞ áöõäñïãïíÜóç.
íá äéáôçñïýí ôç óôÜèìç ôïõ ãáëáêôéêïý óôï áßìá óå ÷á-
ìçëÜ åðßðåäá (0,5–1,5 mEq/L).
ÕÐÅÑÐÁÑÁÃÙÃÇ ÊÁÉ ÁÈÑÏÉÓÇ ÔÏÕ ÃÁËÁÊÔÉÊÏÕ ÏÎÅÏÓ
Ïé êõñéüôåñåò óõíèÞêåò ðïõ ðñïÜãïõí ôçí õðåñðá-
ñáãùãÞ êáé Üèñïéóç ãáëáêôéêïý áöïñïýí óôéò êáôá-
óôÜóåéò éóôéêÞò õðïÜñäåõóçò êáé õðïîßáò.
Óôï êõôôáñéêü åðßðåäï, ïé óõíÝðåéåò ôùí áíùôÝñù êá-
ôáóôÜóåùí åßíáé:
– Ç åîÜíôëçóç ôùí êõôôáñéêþí áðïèåìÜôùí åíÝñãåéáò
(ÁÔÑ) êáé
– Ç äéáôáñá÷Þ ôùí ïîåéäùôéêþí ìéôï÷ïíäñéáêþí ëåé-
ôïõñãéþí ëüãù Ýëëåéøçò ïîõãüíïõ.
Ç áíáðëÞñùóç ôùí åíåñãåéáêþí áðïèåìÜôùí ôïõ êõô-
ôÜñïõ, õðü áõôÝò ôéò óõíèÞêåò, óôñÝöåôáé áíáãêáóôéêÜ
óôçí åíåñãïðïßçóç ôçò áíáåñüâéáò ãëõêüëõóçò, ç á-
ðüäïóç üìùò ôçò ïðïßáò, ëüãù äéáêïðÞò ôçò ëåéôïõñ-
ãßáò ôïõ êýêëïõ ôïõ Krebs (ìéôï÷üíäñéá), åßíáé ðïëý ðå-
ñéïñéóìÝíç. Ãéá íá åîáóöáëéóôåß, óõíåðþò, ç óôïé÷åéþ-
äçò åíåñãåéáêÞ ðáñáãùãÞ, õößóôáôáé áíÜãêç õðåñâï-
ëéêÞò åíåñãïðïßçóçò ôçò áíáåñüâéáò ãëõêüëõóçò, ìå
ôåëéêü áðïôÝëåóìá ôçí ðáñáãùãÞ ìåãÜëùí ðïóïôÞôùí
ðõñïóôáöõëéêïý êáé NaDH, ðïõ äåí ìðïñïýí íá ïîåé-
äùèïýí óôá õðïëåéôïõñãïýíôá ìéôï÷üíäñéá êáé áèñïß-
æïíôáé óôï êõôôáñüðëáóìá ôïõ êõôôÜñïõ. Ç áýîçóç ôçò
óõãêÝíôñùóçò ôïõ ðõñïóôáöõëéêïý êáé ôïõ ëüãïõ
[NaDH]/[NaD+] ïäçãåß, êáôÜ ôçí åîßóùóç (3), óôçí õ-
ðåñðáñáãùãÞ ãáëáêôéêïý ïîÝïò, óôñÝöïíôáò ôç öïñÜ
ôçò áíôßäñáóçò (1) ðñïò ôá äåîéÜ (åéê. 3).
Ï çðáôéêüò (êáé íåöñéêüò) ìåôáâïëéóìüò ôïõ õðåñðá-
ñáãüìåíïõ ãáëáêôéêïý ðáñáâëÜðôåôáé ëüãù áíáóôïëÞò
ôçò ëåéôïõñãßáò ôïõ êýêëïõ ôïõ Krebs óôï çðáôéêü êýô-
ôáñï (Ýëëåéøç ïîõãüíïõ) êáé äéáêïðÞò ôçò íåïãëõêïãÝ-
ÃÁËÁÊÔÉÊÇ ÏÎÅÙÓÇ 453

Ðßíáêáò 1. Áßôéá ãáëáêôéêÞò ïîÝùóçò.

Ôýðïò Á
Shock*
ÊáñäéáêÞ áíáêïðÞ, âáñéÜ êáñäéáêÞ áíåðÜñêåéá*
Ïîåßá áíáðíåõóôéêÞ áíåðÜñêåéá*
ÂáñéÜ áíáéìßá
Äçëçôçñßáóç ìå ìïíïîåßäéï ôïõ Üíèñáêá
Ôýðïò Â
Óáê÷áñþäçò äéáâÞôçò*
ÇðáôéêÞ áíåðÜñêåéá*
ÓÞøç*
ÍåöñéêÞ áíåðÜñêåéá*
ÍåïðëÜóìáôá*
Óðáóìïß, õðåñâïëéêÞ ìõúêÞ Üóêçóç*
ÁëêÜëùóç*
ÖÜñìáêá-ôïîßíåò
– Äéãïõáíßäéá*
Åéêüíá 3. ÁðëïðïéçìÝíç ó÷çìáôéêÞ ðáñÜóôáóç ôïõ áíáåñüâéïõ ìåôá- – ÁéèõëéêÞ áëêïüëç
âïëéóìïý ôïõ êõôôÜñïõ óå óõíèÞêåò éó÷áéìßáò-õðïîßáò. – ÓáëéêõëéêÜ*
– Ìåèáíüëç
– Áéèõëåíïãëõêüëç
íåóçò (ç åíåñãïðïßçóç ôïõ åíæýìïõ öùóöïöñïõêôïêé- – Êõáíéïý÷á
íÜóç áðü ôçí åíäïêõôôÜñéá ìåßùóç ôïõ ÁÔÑ äéåãåßñåé ôç – Ðáñáêåôáìüëç
ãëõêüëõóç êáé áíáóôÝëëåé ôç íåïãëõêïãÝíåóç). – Óïñâéôüëç
– Éóïíéáæßäç
Ï óõíäõáóìüò áõîçìÝíçò ðáñáãùãÞò êáé ìåéùìÝíïõ – ÊïêáÀíç
çðáôéêïý (êáé íåöñéêïý) ìåôáâïëéóìïý ôïõ ãáëáêôéêïý – ÐáñåíôåñéêÞ èñÝøç
ïîÝïò ïäçãïýí óôçí ÜèñïéóÞ ôïõ óôïí ïñãáíéóìü êáé – Èåïöõëëßíç
óôçí áíÜðôõîç ìåôáâïëéêÞò ïîÝùóçò. – Óôñåðôïæïôïêßíç
– ÍïõêëåïóéäéêÜ áíÜëïãá (æéäïâïõäßíç, äéäáíïóßíç ê.Ü.)
– Ëáêôïõëüæç
ÁÉÔÉÁ ÃÁËÁÊÔÉÊÇÓ ÏÎÅÙÓÇÓ
Óõããåíåßò åíæõìéêÝò äéáôáñá÷Ýò
Äéáôáñá÷Ýò íåïãëõêïãÝíåóçò
Ç ôáîéíüìçóç ôçò ãáëáêôéêÞò ïîÝùóçò óôïõò ôýðïõò Á
– ÁíåðÜñêåéá ãëõêïæï-6-öùóöáôÜóçò (ãëõêïãïíßáóç ôýðïõ É)
êáé  âáóßæåôáé óå êëéíéêÜ åõñÞìáôá êáé áðïôåëåß ôï ðñþ- – ÁíåðÜñêåéá öñïõêôïæï-1,6-äéöùóöáôÜóçò
ôï âÞìá óôç äéáöïñéêÞ äéÜãíùóç ôùí áéôßùí ôçò3 (ðßí. 1). – ÁíåðÜñêåéá ðõñïóôáöõëéêÞò êáñâïîõëÜóçò
Äéáôáñá÷Ýò ïîåßäùóçò ðõñïóôáöõëéêïý
Ôýðïò Á – ÁíåðÜñêåéá ðõñïóôáöõëéêÞò áöõäñïãïíÜóçò
– Äéáôáñá÷Ýò ïîåéäùôéêÞò öùóöïñõëßùóçò
Ï ôýðïò Á áíáöÝñåôáé óå êáôáóôÜóåéò ðïõ ÷áñáêôç- ÄéÜöïñá
ñßæïíôáé áðü êëéíéêÜ åìöáíÞ äéáôáñá÷Þ ôçò éóôéêÞò ï- – D-ãáëáêôéêÞ ïîÝùóç
îõãüíùóçò, ìå óõ÷íÜ óõíïäÜ åõñÞìáôá ôçí áñôçñéáêÞ – Õðïãëõêáéìßá
õðüôáóç, ôá óçìåßá ìåéùìÝíçò éóôéêÞò áéìÜôùóçò (êõÜ- * Óõ÷íüôåñá áßôéá
íùóç, øõ÷ñÜ Üêñá) êáé ôïí åëáôôùìÝíï êïñåóìü ôïõ
áñôçñéáêïý áßìáôïò óå ïîõãüíï. ôÝò, ç ðåñéöåñéêÞ áããåéïóýóðáóç åíï÷ïðïéåßôáé ãéá ôçí
Ç êáñäéáêÞ áíáêïðÞ êáé ôï shock áðïôåëïýí ôá óõ- áõîçìÝíç óýíèåóç ãáëáêôéêïý ïîÝïò êáé ç óðëá÷íéêÞ
÷íüôåñá áßôéá ãáëáêôéêÞò ïîÝùóçò êáé óõã÷ñüíùò ÷á- ãéá ôç ìåéùìÝíç çðáôéêÞ ôïõ êÜèáñóç.
ñáêôçñéóôéêÜ ðáñáäåßãìáôá ôçò ïîÝùóçò ôýðïõ Á. Óôï Ç ïîåßá áíáðíåõóôéêÞ áíåðÜñêåéá êáé ç áéöíßäéá á-
óçìåßï áõôü èá ðñÝðåé íá ôïíéóèåß üôé ç åìöÜíéóç ãá- íÜðôõîç âáñéÜò õðïîáéìßáò ðñïäéáèÝôïõí óôçí åìöÜíé-
ëáêôéêÞò ïîÝùóçò óå ëáíèÜíïõóåò ìïñöÝò shock (ð.÷. óç ãáëáêôéêÞò ïîÝùóçò, áí ç áñôçñéáêÞ ïîõãüíùóç å-
óçøáéìßá óå çëéêéùìÝíïõò áóèåíåßò) äåí åßíáé óðÜíéá
ëáôôùèåß óå åðßðåäá <74%.
êáé áðáéôåß êëéíéêÞ åãñÞãïñóç. Óôçí ðåñßðôùóç áõôÞ, ï
êïñåóìüò ôïõ áñôçñéáêïý áßìáôïò åßíáé ó÷åäüí öõóéï- Óôïõò ÷ñüíéïõò áíáðíåõóôéêïýò áóèåíåßò, áíôßèåôá, ç
ëïãéêüò, õðÜñ÷åé äå ãåíéêåõìÝíç áããåéïóýóðáóç, ðïõ áíôéññïðéóôéêÞ ðïëõêõôôáñáéìßá êáé ç áýîçóç ôïõ åñõ-
äéáôçñåß öõóéïëïãéêÞ ôçí áñôçñéáêÞ ðßåóç óå âÜñïò ôçò èñïêõôôáñéêïý 2,3-DPG áóêïýí ðñïóôáôåõôéêÞ äñÜóç
éóôéêÞò áéìÜôùóçò êáé ïîõãüíùóçò. Óôéò êáôáóôÜóåéò áõ- óôçí åìöÜíéóç óïâáñÞò éóôéêÞò õðïîßáò.
454 Ã. ÔÓÏÕÖÁÊÇÓ

Ôýðïò  åìðëÝêïíôáé ìç÷áíéóìïß êáé ôùí äýï ôýðùí ãáëáêôéêÞò

×áñáêôçñßæåôáé áðü áíÜðôõîç ãáëáêôéêÞò ïîÝùóçò
÷ùñßò ôçí ýðáñîç êëéíéêÜ åìöáíþí åíäåßîåùí êõêëï-
öïñéêÞò áíåðÜñêåéáò Þ éóôéêÞò õðïîßáò.
ËåðôÝò äéáôáñá÷Ýò ôçò ìéôï÷ïíäñéáêÞò ëåéôïõñãßáò, ðïõ
åðçñåÜæïõí ôçí ïìáëÞ ÷ñçóéìïðïßçóç ôïõ öõóéïëïãéêÜ
ðñïóöåñüìåíïõ ïîõãüíïõ, êáèþò êáé äéáôáñá÷Ýò ôùí åí-
äéÜìåóùí ìåôáâïëéêþí ïäþí ôçò ãëõêüëõóçò/íåïãëõêï-
ãÝíåóçò, áðïôåëïýí ôïõò ðéèáíïýò ðáèïãåíåôéêïýò ìç-
÷áíéóìïýò. Ïé ðåñéóóüôåñåò, ðÜíôùò, áðü ôéò ÷ñüíéåò áõ-
ôÝò êáôáóôÜóåéò ðñïêáëïýí ó÷åôéêÜ Þðéïõ âáèìïý áýîç-
óç ôïõ ãáëáêôéêïý ïîÝïò êáé ÷ñåéÜæïíôáé åðéðñüóèåôïé
ðáñÜãïíôåò ãéá ôçí áíÜðôõîç êëéíéêÜ åìöáíïýò ìåôáâï-
ëéêÞò ïîÝùóçò. Ïé ðáñÜãïíôåò áõôïß, óôç ìåãÜëç ôïõò
ðëåéïøçößá, ó÷åôßæïíôáé ìå ìåéùìÝíç éóôéêÞ áéìÜôùóç êáé
ïîõãüíùóç, ü÷é üìùò ôüóï Ýêäçëç üóï óôçí ïîÝùóç ôý-
ðïõ Á. Óå ïñéóìÝíåò ìÜëéóôá ðåñéðôþóåéò (ð.÷. åðéëçðôé-
êïß óðáóìïß, õðåñâïëéêÞ ìõúêÞ Üóêçóç), ç éóôéêÞ áõôÞ
õðïÜñäåõóç êáé õðïîßá åßíáé áðëþò ó÷åôéêÞ.
Óôïí ðßíáêá 2 áíáöÝñïíôáé åðéãñáììáôéêÜ ïé ðéèáíïß
ðáèïãåíåôéêïß ìç÷áíéóìïß õðåñðáñáãùãÞò ãáëáêôéêïý
óôéò êõñéüôåñåò ìïñöÝò ãáëáêôéêÞò ïîÝùóçò ôýðïõ Â.
Èá ðñÝðåé, ðÜíôùò, íá óçìåéùèåß üôé óå áñêåôÝò ðå-
ñéðôþóåéò, üðùò ð.÷. óôçí ïîÝùóç ôïõ óçðôéêïý shock,
ïîÝùóçò.11
Áí êáé óðÜíéá (1,3 ðåñéðôþóåéò áíÜ 1.000 èåñáðåõ-
üìåíïõò-Ýôç),12 ç óõíäåüìåíç ìå ôç ÷ñÞóç íïõêëåïóé-
äéêþí áíáëüãùí ãéá ôç èåñáðåßá ôçò HIV-ëïßìùîçò á-
ðïôåëåß ìéá íÝá ìïñöÞ ãáëáêôéêÞò ïîÝùóçò ôýðïõ Â, á-
ðïäéäüìåíç óôçí ôïîéêÞ äñÜóç ôùí áíùôÝñù öáñìÜêùí
óôç ëåéôïõñãßá ôïõ ìéôï÷ïíäñßïõ.12–22
ÊËÉÍÉÊÇ ÅÉÊÏÍÁ – ÅÑÃÁÓÔÇÑÉÁÊÁ ÅÕÑÇÌÁÔÁ
Ç êëéíéêÞ åéêüíá ôçò ãáëáêôéêÞò ïîÝùóçò äåí åßíáé
åéäéêÞ êáé åðéêáëýðôåôáé áðü ôéò åêäçëþóåéò ôçò âáóé-
êÞò íüóïõ.
Ôï ÷Üóìá áíéüíôùí åßíáé áõîçìÝíï ëüãù Üèñïéóçò
ãáëáêôéêïý óôï áßìá (>5 mEq/L). Óõ÷íÜ ðáñáôçñåßôáé
õðåñïõñé÷áéìßá, ç ïðïßá ïöåßëåôáé óôïí áíôáãùíéóìü
ìåôáîý ãáëáêôéêïý êáé ïõñéêïý ïîÝïò ãéá óùëçíáñéáêÞ
Ýêêñéóç óôïí áõëü ôïõ åããýò åóðåéñáìÝíïõ óùëçíáñß-
ïõ. Ç õðåñöùóöáôáéìßá áíôáíáêëÜ ôçí áõîçìÝíç Ýîï-
äï öùóöüñïõ áðü ôá êýôôáñá ëüãù ôçò éóôéêÞò õðïîßáò
êáé ôçò åîÜíôëçóçò ôùí êõôôáñéêþí áðïèåìÜôùí ÁÔÑ,
åíþ ç ëåõêïêõôôÜñùóç åßíáé áðïôÝëåóìá ôçò áõîçìÝ-
íçò Ýêêñéóçò êáôå÷ïëáìéíþí áðü ôç äñÜóç ôçò ïîÝù-
óçò óôá åðéíåöñßäéá.

Ðßíáêáò 2. Ðéèáíïß ðáèïãåíåôéêïß ìç÷áíéóìïß ðñüêëçóçò ãáëáêôéêÞò ïîÝùóçò ôýðïõ  óå äéÜöïñåò ðáèïëïãéêÝò êáôáóôÜóåéò.
Óáê÷áñþäçò äéáâÞôçò
– Éíóïõëéíïðåíßá ÁõîçìÝíïò ìõúêüò êáôáâïëéóìüò ÁõîçìÝíç ðñïóöïñÜ áëáíßíçò
– ÊåôïîÝùóç Õðïïãêáéìßá
Áýîçóç ëüãïõ [NaDH]/[NaD+]
ÌåéùìÝíç çðáôéêÞ ðñüóëçøç ãáëáêôéêïý4
– Áýîçóç åëåýèåñùí
ëéðáñþí ïîÝùí ÁíáóôïëÞ ðõñïóôáöõëéêÞò áöõäñïãïíÜóçò5
– Äéãïõáíßäéá Äéáôáñá÷Þ ëåéôïõñãßáò ìåìâñÜíçò ìéôï÷ïíäñßùí 6
Aýîçóç ðáñáãùãÞò ãáëáêôéêïý óå åîùçðáôéêÝò èÝóåéò 7,8
ÇðáôéêÞ-íåöñéêÞ áíåðÜñêåéá
– ÌåéùìÝíç êÜèáñóç ãáëáêôéêïý
ÍåïðëÜóìáôá
– ÕðåñðáñáãùãÞ ãáëáêôéêïý áðü ôïí üãêï (áõîçìÝíïò ñõèìüò áíáåñüâéáò ãëõêüëõóçò)
– ÅêôåôáìÝíç çðáôéêÞ äéÞèçóç
– ÐáñáãùãÞ ìåôáâïëéôþí ôñõðôïöÜíçò AíáóôïëÞ ìåôáâïëéóìïý ãáëáêôéêïý
– Õðïãëõêáéìßá HðáôéêÞ äõóëåéôïõñãßá, õðåñÝêêñéóç êáôå÷ïëáìéíþí
ÁëêÜëùóç
– Áýîçóç äñáóôçñéüôçôáò öùóöïöñïõêôïêéíÜóçò Áýîçóç ãëõêüëõóçò
– Õðåñáåñéóìüò (áíáðíåõóôéêÞ áëêÜëùóç) YðåñðáñáãùãÞ ãáëáêôéêïý
áðü ôïõò áíáðíåõóôéêïýò ìõò
Áëêïïëéóìüò
– ÁíáóôïëÞ íåïãëõêïãÝíåóçò9
– Áýîçóç ëüãïõ [NaDH]/[NaD+]1,10
Åðéëçðôéêïß óðáóìïß
– ¸íôïíç åíåñãïðïßçóç áíáåñüâéáò ãëõêüëõóçò óêåëåôéêþí ìõþí
ÃÁËÁÊÔÉÊÇ ÏÎÅÙÓÇ 455

ÈÅÑÁÐÅÉÁ ôáé ðåñáéôÝñù åðéâÜñõíóç ôïõ ìåôáâïëéóìïý ôïõ õðåñ-

Ôï áðïöáóéóôéêü âÞìá ãéá ôç èåñáðåõôéêÞ áíôéìåôþ-
ðéóç ôçò ãáëáêôéêÞò ïîÝùóçò åßíáé ç äéüñèùóç ôçò ðñù-
ôïðáèïýò äéáôáñá÷Þò, ôçò õðåýèõíçò ãéá ôçí áíÜðôõîÞ
ôçò. Ç áðïôõ÷ßá åðßôåõîçò áõôïý ôïõ óôü÷ïõ åßíáé óõ-
÷íÜ êáôáäéêáóôéêÞ ãéá ôïí áóèåíÞ.
Ç ÷ïñÞãçóç NaHCO3 óôç ãáëáêôéêÞ ïîÝùóç áðïôå-
ëåß óçìåßï áìöéëåãüìåíï. Ç Ýóôù êáé ðïëý ìéêñÞ áý-
îçóç ôïõ ðïëý ÷áìçëïý pH Ý÷åé èåùñçôéêÜ ôï ðëåïíÝ-
êôçìá ôçò áðïöõãÞò ôùí óïâáñþí êáñäéáêþí áññõè-
ìéþí, ôçò âåëôßùóçò ôçò óõóôáëôéêüôçôáò ôïõ ìõïêáñäß-
ïõ êáé ôçò ìåßùóçò ôçò ðåñéöåñéêÞò áããåéïäéáóôïëÞò,
ìå ôåëéêü áðïôÝëåóìá ôç âåëôßùóç ôçò éóôéêÞò áéìÜôù-
óçò.2,23 Ç áíÜãêç, üìùò, ÷ïñÞãçóçò ìåãÜëùí ðïóïôÞ-
ôùí NaHCO3 åíÝ÷åé ôïí êßíäõíï ôçò êáñäéáêÞò êÜì-
øçò, ôçò õðåñíáôñéáìßáò êáé ôïõ õðåñáêïíôéóìïý ôçò ï-
îåïâáóéêÞò äéáôáñá÷Þò ðñïò ôçí êáôåýèõíóç ôçò ìåôá-
âïëéêÞò áëêÜëùóçò, ìüëéò ç õðïêåßìåíç íüóïò õðï-
÷ùñÞóåé êáé ç ðåñßóóåéá ôïõ ãáëáêôéêïý ìåôáâïëéóôåß
–
ðñïò ðõñïóôáöõëéêü êáé HCO3. Ç âåëôßùóç, åðßóçò, ôùí
áéìïäõíáìéêþí ðáñáìÝôñùí áðü ôç äéüñèùóç ôçò ïîÝ-
ùóçò áìöéóâçôåßôáé áðü ìåñéêïýò.24–26
ÊëéíéêÝò êáé ðåéñáìáôéêÝò ðáñáôçñÞóåéò27 áíáöÝñïõí
áêüìá üôé ç áãùãÞ ìå NaHCO3 åßíáé ìÜëëïí áíáðïôå-
ëåóìáôéêÞ, áöïý ðñïêáëåß ðáñïäéêÞ ìüíï áýîçóç ôçò
óôÜèìçò ôùí äéôôáíèñáêéêþí óôï áßìá. Ç õðåñðáñáãù-
ãÞ ìåãÜëùí ðïóïôÞôùí CO2 áðü ôçí åîïõäåôÝñùóç ôçò
–
ðåñßóóåéáò Ç+ áðü ôá ÷ïñçãïýìåíá HCO3 ïäçãåß óå
ôïðéêÞ ÜèñïéóÞ ôïõ óôïõò éóôïýò êáé ðñüêëçóç åíäï-
êõôôÜñéáò õðåñêáðíßáò êáé ïîÝùóçò.25 Áõôü óõíåðÜãå-
ðáñáãüìåíïõ ãáëáêôéêïý êáé åðéäåßíùóç ôçò ïîÝùóçò.28
ËáìâÜíïíôáò õðüøç ôéò ðáñáðÜíù åðéöõëÜîåéò, ïé ðå-
ñéóóüôåñïé óõìöùíïýí óôç ÷ïñÞãçóç NaHCO3 ìüíï
óôéò ðåñéðôþóåéò ìåãÜëçò ìåßùóçò ôïõ pH ôïõ áßìáôïò
(<7,10–7,15), ìå óôü÷ï ôç äéáôÞñçóÞ ôïõ, áí áõôü åß-
íáé åöéêôü, óå åðßðåäá ðåñß ôï 7,20–7,25.29
Ùò åíáëëáêôéêÝò ëýóåéò Ý÷ïõí äïêéìáóôåß ôá åîÞò: (á)
Calcicarb (ìßãìá NaHCO3 êáé Na2CO3), ôï ïðïßï êáôÜ ôçí
åîïõäåôÝñùóÞ ôïõ äåí ðáñÜãåé CO2 êáé, èåùñçôéêÜ ôïõ-
ëÜ÷éóôïí, áðïôñÝðåé ôçí áðü ôï CO2 ðñïêáëïýìåíç åðé-
âÜñõíóç ôùí áéìïäõíáìéêþí óõíèçêþí ôùí áóèåíþí. Óå
ðåéñáìáôüæùá, ç ÷ïñÞãçóç calcicarb óõíïäåýôçêå áðü óç-
ìáíôéêÞ áýîçóç ôïõ pH,30–33 äåí õðÜñ÷ïõí üìùò åëåã÷ü-
ìåíåò ìåëÝôåò óôïõò áíèñþðïõò. (â) Äé÷ëùñïîéêü (DCA),
ôï ïðïßï äéåãåßñåé ôç äñáóôçñéüôçôá ôçò ðõñïóôáöõëéêÞò
áöõäñïãïíÜóçò êáé ðñïÜãåé ôçí ïîåßäùóç ôïõ ðõñïóôá-
öõëéêïý óå CO2 êáé H2O.34 Oé óïâáñÝò áíåðéèýìçôåò å-
íÝñãåéåò ôïõ DCA (íåõñïôïîéêüôçôá, êáôáññÜêôçò, âëÜâç
ôùí üñ÷åùí, äéáôáñá÷Þ ôïõ ìåôáâïëéóìïý ôùí ïîáëéêþí)
áðïêëåßïõí ôç ìáêñï÷ñüíéá ÷ñÞóç ôïõ êáé Ý÷ïõí ðåñéï-
ñßóåé ôçí åõñåßá åöáñìïãÞ ôïõ óôçí êëéíéêÞ ðñÜîç. (ã) Ù-
ìÝãá-3 ëéðáñÜ ïîÝá, ôá ïðïßá Üìâëõíáí ôçí ðñïêáëïý-
ìåíç áðü åíäïôïîßíåò ãáëáêôéêÞ ïîÝùóç óå ðåéñáìáôü-
æùá.35 (ä) Èåéáìßíç, óå ðåñéðôþóåéò óõããåíïýò áíåðÜñ-
êåéáò ôùí åíæõìéêþí óõóôçìÜôùí ìåôáâïëéóìïý ôïõ ðõ-
ñïóôáöõëéêïý (ðõñïóôáöõëéêÞ áöõäñïãïíÜóç êáé êáñ-
âïîõëÜóç)36 êáé óå ãáëáêôéêÞ ïîÝùóç áðü íïõêëåïóéäé-
êÜ áíÜëïãá,37 ìå éêáíïðïéçôéêÜ áðïôåëÝóìáôá. (å) Óå ìå-
ìïíùìÝíåò ðåñéðôþóåéò Ý÷ïõí ÷ñçóéìïðïéçèåß ôüóï ç áé-
ìïêÜèáñóç üóï êáé ç ðåñéôïíáúêÞ êÜèáñóç.

ABSTRACT

Lactic acidosis
G. TSOUFAKIS
Department of Nephrology, “G. Gennimatas”
General District Hospital, Athens, Greece
Archives of Hellenic Medicine 2001, 18(5):451–456

Lactic acidosis is one of the most frequent forms of nosocomial metabolic acidosis. The overproduction and
accumulation of lactic acid in the tissues develops under conditions of tissue hypoxia and hypoperfusion, and
is associated with disturbances in mitochondrial function. Cardiac arrest, shock, sepsis, and cardiac and res-
piratory insufficiency constitute the most frequent causes of lactic acidosis in the clinical setting. Treatment is
effective only when it achieves resolution of the primary cause which provoked the acidosis. Bicarbonate ad-
ministration is rather ineffective, and is reserved for cases with arterial pH <7.10–7.15 only. Alternative the-
rapeutic regimes have been used including calcicarb, dichloroacetate, thiamine, n-3 fatty acids, without their
effect being clinically established.

Key words:: Bicarbonates, Lactate, Lactic acid, Metabolic acidosis

456
Âéâëéïãñáößá
1. KREISBERG RA. Lactic acidosis. An update. J Intens Care Med 1987,
2:76–84
2. MADIAS N. Lactic acidosis. Kidney Int 1986, 29:752–774
3. COHEN RD, WOODS HF. Lactic acidosis revisited. Diabetes 1983,
32:181–191
4. METCALFE HK, MONSON JP, WELCH SG. Inhibition of lactate removal
by ketone bodies in rat liver: Evidence for a quantitatively im-
portant role of the plasma membrane lactate transporter in lac-
tate metabolism. J Clin Invest 1986, 78:743–747
5. STACPOOLE PW. Lactic acidosis and other mitochondrial dis-
orders. Metabolism 1997, 46:306–321
6. LALAU JD, RACE JM. Lactic acidosis in metformin therapy. Drugs
1999, 58(Suppl 1):55–60
7. KRENTZ AJ, FERNER RE, BAILEY CJ. Comparative tolerability profiles of
oral antidiabetic agents. Drug Saf 1994, 11:223–241
8. BAILEY CJ, WILCOCK C, DAY C. Effect of metformin on glucose
metabolism in the splanchnic bed. Br J Pharmacol 1992, 105:
1009–1013
9. KREISBERG RA, OWEN WC, SIEGAL AM. Ethanol-induced hyper-
lactemia: Inhibition of lactate utilization. J Clin Invest 1971, 50:
166–174
10. FULOP M, BOCK J, BEN-EZRA J. Plasma lactate and 3-hydroxybutyrate
levels in patients with acute ethanol intoxication. Am J Med 1986,
80:191–194
11. STACPOOLE PW. Lactic acidosis. Endocrinol Metab Clin North Am
1993, 22:221–245
12. FORTGANG IS, BELITSOS PC, CHAISSON RE. Hepatomegaly and steato-
sis in HIV-infected patients receiving nucleoside analog antire-
troviral therapy. Am J Gastroenterol 1995, 90:1433–1436
13. FREIMAN JP, HELFERT KE, HAMRELL MR. Hepatomegaly with severe
steatosis in HIV-seropositive patients. AIDS 1993, 7:379–385
14. OLANO JP, BORUCKI MJ, WEN JW. Massive hepatic steatosis and lac-
tic acidosis in a patient with AIDS who was receiving zidovudine.
Clin Infect Dis 1995, 21:973–976
15. BISSUEL F, BRUNEEL F, HABERSETZER F. Fulminant hepatitis with se-
vere lactate acidosis in HIV-infected patients on didanosine ther-
apy (case report). J Intern Med 1994, 235:367–372
16. McKENZIE R, FRIED MW, SALLIE R. Hepatic failure and lactic acidosis
due to fialuridine (FIAU), an investigational nucleoside analogue
for chronic hepatitis B. N Engl J Med 1995, 333:1099–1105
17. CHATTHA G, ARIEFF AI, CUMMINGS C. Lactic acidosis complicating the
acquired immunodeficiency syndrome. Ann Intern Med 1993,
118:37–39
18. GOPINATH R, HUTCEON M, CHEEMA-DHADLI S. Chronic lactic acido-
sis in a patient with acquired immunodeficiency syndrome and
mitochondrial myopathy: Biochemical studies. J Am Soc Nephrol
1992, 3:1212–1219
19. MODICA-NAPOLITANO JS. AZT causes tissue-specific inhibition of
mitochondrial bioenergetic function. Biochem Biophys Res Com-
mun 1993, 194:170–177
20. SUNDAR K, SUAREZ M, BANOGON PE, SHAPIRO JM. Zidovudine-indu-
ced fatal lactic acidosis and hepatic failure with acquired immun-
Ã. ÔÓÏÕÖÁÊÇÓ
odeficiency syndrome: Report of two patients and review of the
literature. Crit Care Med 1997, 25:1425–1430
21. MOKRYCKI MH, HARRIS C, MAY H, LAUT J, PALMISANO J. Lactic acido-
sis associated with stavudine administration: A report of five
cases. Clin Infect Dis 2000, 30:198–200
22. ROY PM, GOUELLO JP, PENNISON-BESNIER I, CHENNEBAULT JM. Severe
lactic acidosis induced by nucleoside analogues in a HIV-infected
man. Ann Emerg Med 1999, 34:282–284
23. NARINS RG, COHEN JJ. Bicarbonate therapy for organic acidoses:
The case for its continued use. Ann Intern Med 1987, 106:615–
618
24. FORSYTHE SM, SCHMIDT GA. Sodium bicarbonate for the treatment
of lactic acidosis. Chest 2000, 117:260–267
25. COOPER DJ, WALLEY KR, WIGGS BR, RUSSEL JA. Bicarbonate does not
improve hemodynamics in critically ill patients who have lactic
acidosis. Ann Intern Med 1990, 112:492–498
26. KETTE F, WEIL MH, VON PLANTA M, GAZMURI RJ, RACKOW EC. Buffer
agents do not reserve intramyocardial acidosis during cardiac
resuscitation. Circulation 1990, 81:1660–1666
27. STACPOOLE PW. Lactic acidosis: The case against bicarbonate ther-
apy. Ann Intern Med 1986, 105:276–279
28. GRAF H, LEACH W, ARIEF AI. Evidence for a detrimental effect of
bicarbonate therapy in hypoxic lactic acidosis. Science 1985,
227:754–756
29. HINDMAN BJ. Sodium bicarbonate in the treatment of subtypes of
acute lactic acidosis: Physiologic consideration. Anesthesiology
1990, 72:1064–1076
30. SUN JH, FILLEY GF, HORD K. Calcicarb: an effective substitute for
NaHCO3 for the treatment of acidosis. Surgery 1987, 5:835–839
31. RHEE KH, TORO LO, McDONALD GG. Calcicarb, sodium bicarbonate,
and sodium chloride in hypoxic lactic acidosis: effect on arterial
blood gases, lactate concentrations, hemodynamic variables,
and myocardial intracellular pH. Chest 1993, 104:913–918
32. KLEPPER ID, KUCERA RF, KINDING NB. A comparative study of sodium
bicarbonate and calcicarb in the treatment of metabolic acidosis
induced by hemorrhagic shock. J Crit Care 1988, 3:256–161
33. BERSIN RM, ARIEFF AI. Improved hemodynamic function during
hypoxia with calcicarb, a new agent for the management of aci-
dosis. Circulation 1988, 77:227–233
34. STACPOOLE PW. The pharmacology of dichloroacetate. Meta-
bolism 1989, 38:1124–1144
35. POMPOSELLI JJ, FLORES EA, HIRSCHBERG Y. Short-term TPN contain-
ing n-3 fatty acids ameliorate lactic acidosis induced by endo-
toxin in guinea pigs. Am J Clin Nutr 1990, 52:548–552
36. BRUNETTE MG, DELVIN E, HAZEL B. Thiamine responsive lactic aci-
dosis in a patient with deficient low-km pyruvate carboxylase
activity in liver. Pediatrics 1972, 50:702–711
37. SCHRAMM C, WANITSCHKE R, GALLE PR. Thiamine for the treatment
of nucleoside analogue-induced severe lactic acidosis. Eur J
Anaesthesiol 1999, 16:733–735
Corresponding author:
G. Tsoufakis, 5 Asprogeraka street, GR-117 44 Athens, Greece