levels finally improved to 1.9 mmol/L and creatinine normalized to 0.75 mg/dL. She was weaned off of mechanical ventilation, changed to an alternative anti-retroviral, and discharged with follow-up. Discussion: Lactic acidosis can arise from multiple factors, including NRTIs. Although newer NRTIs such as tenofovir alafenamide (used in Biktarvy) have improved safety profiles, there are case reports of lactic acidosis associated with incorrect dosing or overuse. This risk may be further increased with long-term usage, liver disease, female sex, rapid weight gain, reduced creatinine clearance and concurrent use of other medications. The lactic acidosis may be attributed to mitochondrial toxicity by NRTIs which reduces oxidative phosphorylation and ATP production. This promotes anaerobic metabolism, producing lactic acid as a byproduct. In our case, the patient’s acute renal failure and underlying metabolic disturbance, alongside reduced creatinine clearance may have increased the risk of drug-induced lactic acidosis.
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