Bauer

E. F. Atte

J. van Griensven

Lonergan

Manfredi

Moyle

Ogedegbe

T. Reid

Crossref

Symptomatic Hyperlactatemia: Lessons Learned Using a Point-of-Care Device in a Health Care Center- and Nurse-Based Antiretroviral Program in Rwanda

van Griensven, J

Atte, E

Reid, T

MSF Field Research

320 • CID 2008:46 (15 January) • CORRESPONDENCE
1 5 J A N U A R Y
Correspondence
Table 1. Lessons learned in a health care center– and nurse-based antiretroviral treatment program.
Experience with a clinical approach
Given practical training, protocols, and supervision, nurses are able to recognize SH/LA readily and to initiate clinical management
Ready access to care, located in health care centers, encourages early diagnosis
Potential advantages of a POCD for determination of the lactate level
High predictive value of normal or high lactate level (5 mmol/L)
Potential for less switching of treatment regimens (SH/LA can be ruled out)
Potential for more-accurate and earlier diagnosis, with
Less morbidity or mortality and/or shorter therapy interruption
More-controlled treatment interruptions (“tail-protection”)
Higher chance of successful rechallenge (particularly zidovudine)
Easy application in health care centers and is user-friendlya
Facilitation of training and enhances confidence of medical staff in the diagnosis and management of SH/LA
Potentially cost-effective, by reducing morbidity/mortality and fewer switches to more-expensive drugs
Potential problems with a POCD for lactate testing
Few data on incidence and clinical significance of subclinical hyperlactatemia in Africa
Requirements for sample collection not assessed in antiretroviral treatment programs in Africa include risk of transient or artificial
increases in the lactate level caused by, for example, exercise, dehydration, feeding, or infection (e.g., malaria)
Potential for overswitching of treatment (associated with false-positive results) if there is poor clinical judgment or training
Laboratory errors or artificial increases
Poor correlation of symptoms with lactate levels
Frequent occurrence of mimicking conditions
Different case definitions of SH have been used in Africa [1, 5, 6], and the optimal threshold of lactate level for treatment interrup-
tion is not known
Although lactate levels correlate with disease severity, substantial variability exists at the individual level [6, 7]
Potential delays in restarting antiretroviral treatment after clinical recovery without clinical benefit
Currently expensive (MSF price, excluding taxes, $226 per machine and $2.3 per test strip)
Requires steady supply of test strips and control solution
NOTE. MSF, Me´decins Sans Frontie`res; POCD, point-of-care device; SH/LA, symptomatic hyperlactatemia/lactic acidosis.
a Defined as a device that is hand-held or portable, that requires minimal training, that provides results in 60 s, that can be used with whole blood
(finger-prick), that is battery driven (1.5 V), that does not require refrigeration, and for which control solutions for performance checks are available [3].
Symptomatic
Hyperlactatemia: Lessons
Learned Using a Point-of-
Care Device in a Health Care
Center– and Nurse-Based
Antiretroviral Program in
Rwanda
To the Editor—We read with interest
the article by Songa et al. [1], because we
are similarly confronted with the frequent
occurrence of symptomatic hyperlacta-
temia/lactic acidosis (SH/LA) in our pro-
gram in Rwanda. With current efforts to
decentralize antiretroviral treatment, most
patients will soon receive treatment
through health care centers that are staffed
mainly by nurses and that have fewer di-
agnostic tools available. Songa and col-
leagues encourage field-testing of point-
of-care devices (POCDs) in Africa. We
report our experience with access to a
POCD at a health care center– and nurse-
based antiretroviral treatment program.
Me´decins Sans Frontie`res started offer-
ing antiretroviral treatment on a decen-
tralized level in Rwanda in 2003, sup-
porting 2 urban government clinics in
Kigali [2]. The program relies extensively
on nurses for provision of care and has
seen a fast scaling-up (i.e., 13000 patients
have started receiving treatment).
In 2005, a standardized clinical protocol
was developed to screen for mitochondrial
toxicities. With training and after use of
the protocol, nurses developed good clin-
ical skills, initiating treatment changes un-
der medical supervision. A high rate of
lipoatrophy was observed [2].
In 2006, a POCD for determination of
the lactate level (Accutrend Lactate;
CORRESPONDENCE • CID 2008:46 (15 January) • 321
Roche) [3] was introduced for patients
with clinically suspected SH/LA. We used
this tool to document 20 cases of SH/LA
[4] and to validate our clinical protocol.
We note some advantages and concerns
regarding this POCD in table 1.
We also reviewed 48 patient files that
noted that symptom-triggered determi-
nation of the lactate level was performed.
For 8 cases (17%), the POCD improved
our clinical management significantly: a
normal value ruled out the diagnosis,
whereas a high value (i.e., 5 mmol/L)
confirmed the diagnosis and avoided de-
lays that normally occur during the clinical
assessment. For 35 cases (73%), the results
did not improve our clinical management;
these cases involved mild or moderate
symptoms and nonsevere elevations in the
lactate level, for which clinical judgment
remains pivotal. Such cases present a
number of challenges.
The potential for artificial elevations in
the lactate level is high [8–10], particularly
in a resource-limited setting, where pa-
tients often walk for hours in hot weather
to visit the clinic and face long waiting
periods. Despite recommendations re-
garding adequate preparation for testing
[11], it is challenging to ensure that the
patient is well hydrated, has been fasting,
and has avoided exercise. Given the
unique circumstances in Africa, additional
studies are needed to balance the POCD’s
validity against its feasibility and accept-
ability [9]. Even then, the true incidence
of subclinical hyperlactatemia has to be
defined, because this will clearly affect the
predictive value of a particular lactate level
[12]. Given their nonspecific nature,
symptoms suggestive of SH/LA have been
shown to correlate poorly with lactate lev-
els and have not consistently improved
with switches or interruptions in treat-
ment, making the diagnosis of mild or
moderate symptomatic hyperlactatemia
challenging and requiring substantial clin-
ical judgement [13–15]. With the signifi-
cant number of diseases in Africa that can
mimic SH/LA on the basis of transient
hyperlactatemia, we have to guard against
overdiagnosis. On the other hand, with
infectious diseases considered to be po-
tential triggers for SH/LA [8, 12], the as-
sumption that subclinical hyperlactatemia
rarely progresses to severe disease [9] has
to be reassessed in Africa.
Another issue is whether the POCD can
assist in the timing of reinitiation of ther-
apy. Although normalization of the lactate
level is generally recommended, the op-
timal time to reinitiation has not been es-
tablished [9]. We have observed clinical
recovery before biochemical recovery and
have rarely seen cases of recurrence using
our clinical approach. Given the risk of
severe infection (particularly tuberculosis)
during treatment interruption, returning
to antiretroviral treatment as soon as pos-
sible is important. Correlation of POCD
results and clinical status will be an im-
portant operational research question.
The optimal use of a POCD remains to
be determined, but if used with a stan-
dardized approach and investment in clin-
ical training for nurses, the POCD can be
a useful device in resource-poor settings.
Acknowledgments
Potential conflicts of interest. All authors: no
conflicts.
Johan van Griensven,1 Edi F. Atte´,1
and Tony Reid2
1Me´decins Sans Frontie`res, Kimihurura, Kacyiru,
Kigali, Rwanda; and 2Me´decins Sans Frontieres,
Operational Centre Brussels, Belgium
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Reprints or correspondence: Dr. Johan van Griensven Me´-
decins Sans Frontie`res, Rue Dupre´ 94, 1090 Brussels, Belgium
(jvgrie@yahoo.com).
Clinical Infectious Diseases 2008; 46:320–2
 2008 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2008/4602-0027$15.00
DOI: 10.1086/524085


Symptomatic hyperlactatemia: lessons learned using a point-of-care device in a health care center- and nurse-based antiretroviral program in Rwanda.

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Symptomatic hyperlactatemia: lessons learned using a point-of-care device in a health care center- and nurse-based antiretroviral program in Rwanda.

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