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Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, Mégarbane B, Hassanian-Moghaddam H, Rif M, Kallab S, Bird S, Wood DM, Roberts DM, Anseeuw K, Berling I, Bouchard J, Bunchman TE, Calello DP, Chin PK, Doi K, Galvao T, Goldfarb DS, Hoegberg LCG, Kebede S, Kielstein JT, Lewington A, Li Y, Macedo EM, MacLaren R, Mowry JB, Nolin TD, Ostermann M, Peng A, Roy JP, Shepherd G, Vijayan A, Walsh SJ, Wong A, Yates C. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2023; 27:56. [PMID: 36765419 PMCID: PMC9921105 DOI: 10.1186/s13054-022-04227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/18/2022] [Indexed: 02/12/2023] Open
Abstract
Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.
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Affiliation(s)
- Marc Ghannoum
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada ,grid.137628.90000 0004 1936 8753Nephrology Division, NYU Langone Health, NYU Grossman School of Medicine, New York, NY USA ,grid.5477.10000000120346234Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Gosselin
- grid.420748.d0000 0000 8994 4657Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC Canada ,grid.86715.3d0000 0000 9064 6198Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada ,Centre Antipoison du Québec, Quebec, QC Canada
| | - Robert S. Hoffman
- grid.137628.90000 0004 1936 8753Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Valery Lavergne
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada
| | - Bruno Mégarbane
- grid.411296.90000 0000 9725 279XDepartment of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Hossein Hassanian-Moghaddam
- grid.411600.2Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Siba Kallab
- grid.411323.60000 0001 2324 5973Department of Internal Medicine-Division of Nephrology, Lebanese American University - School of Medicine, Byblos, Lebanon
| | - Steven Bird
- Department of Emergency Medicine, U Mass Memorial Health, U Mass Chan Medical School, Worcester, MA USA
| | - David M. Wood
- grid.13097.3c0000 0001 2322 6764Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, and Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Darren M. Roberts
- grid.430417.50000 0004 0640 6474New South Wales Poisons Information Centre, Sydney Children’s Hospitals Network, Westmead, NSW Australia ,grid.413249.90000 0004 0385 0051Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW Australia
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Roberts DM, Hoffman RS, Brent J, Lavergne V, Hovda KE, Porter WH, McMartin KE, Ghannoum M. The serum glycolate concentration: its prognostic value and its correlation to surrogate markers in ethylene glycol exposures. Clin Toxicol (Phila) 2022; 60:798-807. [PMID: 35323087 DOI: 10.1080/15563650.2022.2049811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Ethylene glycol poisoning manifests as metabolic acidemia, acute kidney injury and death. The diagnosis and treatment depend on history and biochemical tests. Glycolate is a key toxic metabolite that impacts prognosis, but assay results are not widely available in a clinically useful timeframe. We quantitated the impact of serum glycolate concentration for prognostication and evaluated whether more readily available biochemical tests are acceptable surrogates for the glycolate concentration. OBJECTIVES The objectives of this study are to 1) assess the prognostic value of the initial glycolate concentration on the occurrence of AKI or mortality in patients with ethylene glycol exposure (prognostic study); 2) identify surrogate markers that correlate best with glycolate concentrations (surrogate study). METHODS A systematic review of the literature was performed using Medline/PubMed, EMBASE, Cochrane library, conference proceedings and reference lists. Human studies reporting measured glycolate concentrations were eligible. Glycolate concentrations were related to categorical clinical outcomes (acute kidney injury, mortality), and correlated with continuous surrogate biochemical measurements (anion gap, base excess, bicarbonate concentration and pH). Receiver operating characteristic curves were constructed to calculate the positive predictive values and the negative predictive values of the threshold glycolate concentrations that predict acute kidney injury and mortality. Further, glycolate concentrations corresponding to 100% negative predictive value for mortality and 95% negative predictive value for acute kidney injury were determined. RESULTS Of 1,531 articles identified, 655 were potentially eligible and 32 were included, reflecting 137 cases from 133 patients for the prognostic study and 154 cases from 150 patients for the surrogate study. The median glycolate concentration was 11.2 mmol/L (85.1 mg/dL, range 0-38.0 mmol/L, 0-288.8 mg/dL), 93% of patients were treated with antidotes, 80% received extracorporeal treatments, 49% developed acute kidney injury and 13% died. The glycolate concentration best predicting acute kidney injury was 12.9 mmol/L (98.0 mg/dL, sensitivity 78.5%, specificity 88.1%, positive predictive value 86.4%, negative predictive value 80.9%). The glycolate concentration threshold for a 95% negative predictive value for acute kidney injury was 6.6 mmol/L (50.2 mg/dL, sensitivity 96.9%, specificity 62.7%). The glycolate concentration best predicting mortality was 19.6 mmol/L (149.0 mg/dL, sensitivity 61.1%, specificity 81.4%, positive predictive value 33.3%, negative predictive value 93.2%). The glycolate concentration threshold for a 100% negative predictive value for mortality was 8.3 mmol/L (63.1 mg/dL, sensitivity 100.0%, specificity 35.6%). The glycolate concentration correlated best with the anion gap (R2 = 0.73), followed by bicarbonate (R2 = 0.57), pH (R2 = 0.50) and then base excess (R2 = 0.25), while there was no correlation between the glycolate and ethylene glycol concentration (R2 = 0.00). These data can assist clinicians in planning treatments such as extracorporeal treatments and prognostication. Potentially, they may also provide some reassurance regarding when extracorporeal treatments can be delayed while awaiting the results of further testing in patients in whom ethylene glycol poisoning is suspected but not yet confirmed. CONCLUSIONS This systematic review demonstrates that the glycolate concentration predicts mortality (unlikely if <8 mmol/L [61 mg/dL]). The anion gap is a reasonable surrogate measurement for glycolate concentration in the context of ethylene glycol poisoning. The findings are mainly based on published retrospective data which have various limitations. Further prospective validation studies are of interest.
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Affiliation(s)
- Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NY, USA
| | - Jeffrey Brent
- Departments of Medicine and Emergency Medicine, University of Colorado, School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - William H Porter
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center Lexington, KY, USA
| | | | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
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Nekoukar Z, Zakariaei Z, Taghizadeh F, Musavi F, Banimostafavi ES, Sharifpour A, Ebrahim Ghuchi N, Fakhar M, Tabaripour R, Safanavaei S. Methanol poisoning as a new world challenge: A review. Ann Med Surg (Lond) 2021; 66:102445. [PMID: 34141419 PMCID: PMC8187162 DOI: 10.1016/j.amsu.2021.102445] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Methanol poisoning (MP) occurs often via ingestion, inhalation, or dermal exposure to formulations containing methanol in base. Clinical manifestations of MP include gastrointestinal symptoms, central nervous system (CNS) suppression, and decompensated metabolic acidosis occurred with blurred vision and early or late blindness. OBJECTIVE This study reviewed the clinical manifestations, laboratory and radiology findings, and treatment approaches in MP. DISCUSSION Methanol is usually rapidly absorbed after ingestion and metabolized by alcohol dehydrogenase (ADH), then distributed to the body water to reach a volume distribution approximately equal to 0.77 L/kg. It is also eliminated from the body as unchanged parent compounds. Clinical manifestations of MP alone initiate within 0.5-4 h after ingestion and include gastrointestinal symptoms and CNS suppression. After a latent period of 6-24 h, depending on the absorbed dose, decompensated metabolic acidosis occurs with blurred vision and early or late blindness. Blurred vision with normal consciousness is a strong suspicious sign of an MP. The mortality and severity of intoxication are well associated with the severity of CNS depression, hyperglycemia, and metabolic acidosis, but not with serum methanol concentration. After initial resuscitation, the most important therapeutic action for patients with known or suspected MP is correction of acidosis, inhibition of ADH, and hemodialysis. CONCLUSION Since MP is associated with high morbidity and mortality, it should be considered seriously and instantly managed. Delay in treatment may cause complications, permanent damage, and even death.
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Affiliation(s)
- Zahra Nekoukar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zakaria Zakariaei
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
- Toxicology and Forensic Medicine Division, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Taghizadeh
- Psychiatry and Behavioral Sciences Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Musavi
- Toxicology and Forensic Medicine Division, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Elham Sadat Banimostafavi
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Sharifpour
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
- Pulmonary and Critical Care Division, Imam Khomeini Hospital, Iranian National Registry Center for Lophomoniasis (INRCL), Mazandaran University of Medical Sciences, Sari, Iran
| | - Nasrin Ebrahim Ghuchi
- Knowledge and Information Science, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Rabeeh Tabaripour
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sepideh Safanavaei
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
- Pulmonary and Critical Care Division, Imam Khomeini Hospital, Iranian National Registry Center for Lophomoniasis (INRCL), Mazandaran University of Medical Sciences, Sari, Iran
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Patel R, Mistry AM, Mistry CM. Unintentional Ethylene Glycol Poisoning in an Adolescent. Cureus 2020; 12:e11521. [PMID: 33354465 PMCID: PMC7746011 DOI: 10.7759/cureus.11521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The differential diagnosis is broad when a patient presents with an altered mental status. Ethylene glycol poisoning, a life-threatening condition, can occur as an intentional self-harm attempt or unintentional consumption. It is metabolized in the liver by a series of enzymes, and the metabolites so formed are responsible for the majority of clinical effects. The diverse range of clinical effects includes central nervous system (CNS), gastrointestinal, cardiovascular system (CVS), pulmonary as well as renal effects. The evidence of metabolic acidosis, elevated anion gap, high osmolal gap, and calcium oxalate crystals in laboratory analysis strongly suggests ethylene glycol poisoning. The treatment traditionally consists of alcohol dehydrogenase inhibitors such as fomepizole or ethanol, and in some cases, hemodialysis is needed as well.
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Affiliation(s)
- Rutul Patel
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College (NHLMMC), Ahmedabad, IND
| | - Anuja Mahesh Mistry
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College (NHLMMC), Ahmedabad, IND
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Prediction and validation of the duration of hemodialysis sessions for the treatment of acute ethylene glycol poisoning. Kidney Int 2017; 92:453-460. [DOI: 10.1016/j.kint.2017.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 02/13/2017] [Accepted: 02/16/2017] [Indexed: 11/18/2022]
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Collister D, Duff G, Palatnick W, Komenda P, Tangri N, Hingwala J. A Methanol Intoxication Outbreak From Recreational Ingestion of Fracking Fluid. Am J Kidney Dis 2017; 69:696-700. [PMID: 28111025 DOI: 10.1053/j.ajkd.2016.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/13/2016] [Indexed: 12/21/2022]
Abstract
Single-patient methanol intoxications are a common clinical presentation, but outbreaks are rare and usually occur in settings in which there is limited access to ethanol and methanol is consumed as a substitute. In this case report, we describe an outbreak of methanol intoxications that was challenging from a public health perspective and discuss strategies for managing such an outbreak.
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Affiliation(s)
- David Collister
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Health Sciences Center, Chronic Disease Innovation Centre, Winnipeg, Canada; Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Canada.
| | - Graham Duff
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Wesley Palatnick
- Health Sciences Center, Chronic Disease Innovation Centre, Winnipeg, Canada; Department of Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | - Paul Komenda
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Canada
| | - Navdeep Tangri
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Canada
| | - Jay Hingwala
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Health Sciences Center, Chronic Disease Innovation Centre, Winnipeg, Canada
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Ethylene Glycol Poisoning: An Unusual Cause of Altered Mental Status and the Lessons Learned from Management of the Disease in the Acute Setting. Case Rep Crit Care 2016; 2016:9157393. [PMID: 27847651 PMCID: PMC5099479 DOI: 10.1155/2016/9157393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/24/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
Abstract
Ethylene glycol is found in many household products and is a common toxic ingestion. Acute ingestions present with altered sensorium and an osmolal gap. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. Early intervention is key; however, diagnosis is often delayed, especially in elderly patients presenting with altered mental status. There are several laboratory tests which can be exploited for the diagnosis, quantification of ingestion, and monitoring of treatment, including the lactate and osmolal gaps. As methods of direct measurement of ethylene glycol are often not readily available, it is important to have a high degree of suspicion based on these indirect laboratory findings. Mainstay of treatment is bicarbonate, fomepizole or ethanol, and, often, hemodialysis. A validated equation can be used to estimate necessary duration of hemodialysis, and even if direct measurements of ethylene glycol are not available, monitoring for the closure of the anion, lactate, and osmolal gaps can guide treatment. We present the case of an elderly male with altered mental status, acute kidney injury, elevated anion gap metabolic acidosis, and profound lactate and osmolal gaps.
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Kim Y. Plotting of Ethylene Glycol Blood Concentrations Using Linear Regression before and during Hemodialysis in a Case of Intoxication and Pharmacokinetic Review. Case Rep Nephrol 2015; 2015:359101. [PMID: 26346463 PMCID: PMC4543587 DOI: 10.1155/2015/359101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/22/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction. As blood concentration measurement of commonly abused alcohol is readily available, the equation was proposed in previous publication to predict the change of their concentration. The change of ethylene glycol (EG) concentrations was studied in a case of intoxication to estimate required time for hemodialysis (HD) using linear regression. Case Report. A 55-year-old female with past medical history of seizure disorder, bipolar disorder, and chronic pain was admitted due to severe agitation. The patient was noted to have metabolic acidosis with elevated anion gap and acute kidney injury, which prompted blood concentration measurement of commonly abused alcohol. Her initial EG concentration was 26.45 mmol/L. Fomepizole therapy was initiated, soon followed by HD to enhance clearance. Discussion. Plotting of natural logarithm of EG concentrations over time showed that EG elimination follows first-order kinetics and predicts the change of its concentration well. Pharmacokinetic review revealed minimal elimination of EG by alcohol dehydrogenase (ADH) which could be related to genetic predisposition for ADH activity and home medications as well as presence of propylene glycol. Pharmacokinetics of EG is relatively well studied with published parameters. Consideration and application of pharmacokinetics could assist in management of EG intoxication including HD planning.
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Affiliation(s)
- Youngho Kim
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, 901 University Boulevard SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106, USA
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Prediction and validation of hemodialysis duration in acute methanol poisoning. Kidney Int 2015; 88:1170-7. [PMID: 26244924 PMCID: PMC4653586 DOI: 10.1038/ki.2015.232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 05/29/2015] [Accepted: 06/04/2015] [Indexed: 11/17/2022]
Abstract
The duration of hemodialysis (HD) in methanol poisoning (MP) is dependent on the methanol concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. However, methanol assays are not easily available, potentially leading to undue extension or premature termination of treatment. Here we provide a prediction model for the duration of high-efficiency HD in MP. In a retrospective cohort study, we identified 71 episodes of MP in 55 individuals who were treated with alcohol dehydrogenase inhibition and HD. Four patients had residual visual abnormality at discharge and only one patient died. In 46 unique episodes of MP with high-efficiency HD the mean methanol elimination half-life (T1/2) during HD was 108 min in women, significantly different from the 129 min in men. In a training set of 28 patients with MP, using the 90th percentile of gender-specific elimination T1/2 (147 min in men and 141 min in women) and a target methanol concentration of 4 mmol/l allowed all cases to reach a safe methanol of under 6 mmol/l. The prediction model was confirmed in a validation set of 18 patients with MP. High-efficiency HD time in hours can be estimated using 3.390 × (Ln (MCi/4)) for women and 3.534 × (Ln (MCi/4)) for men, where MCi is the initial methanol concentration in mmol/l, provided that metabolic acidosis is corrected.
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10
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Abstract
Accidental or intentional ingestion of substances containing methanol and ethylene glycol can result in death, and some survivors are left with blindness, renal dysfunction, and chronic brain injury. However, even in large ingestions, a favorable outcome is possible if the patient arrives at the hospital early enough and the poisoning is identified and appropriately treated in a timely manner. This review covers the common circumstances of exposure, the involved toxic mechanisms, and the clinical manifestations, laboratory findings, and treatment of methanol and ethylene glycol intoxication.
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11
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Hekmat R, Samini F, Dadpour B, Maghsudloo F, Mojahedi MJ. Should Guidelines for Conventional Hemodialysis Initiation in Acute Methanol Poisoning, Be Revised, When no Fomepizloe is Used? IRANIAN RED CRESCENT MEDICAL JOURNAL 2012; 14:743-5. [PMID: 23396807 PMCID: PMC3560547 DOI: 10.5812/ircmj.3467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 04/21/2012] [Accepted: 05/12/2012] [Indexed: 12/05/2022]
Abstract
Background Consumption of home-distilled alcohol may lead to epidemic or sporadic cases of severe acute methanol poisoning. The difficulty of establishing strict indications for hemodialysis in acute methanol poisoning is a widely recognized issue. Materials and Methods The determination of the clinical, especially hemodialysis, and para clinical factors influencing patient survival in 46 acutely methanol poisoned patients was the aim of this cross sectional retrospective study. Clinical and paraclinical variables compared in surviving and non-surviving patients were hemodialysis and ventilation requirements, the level of consciousness, ABG parameters the serum methanol, creatinine and BUN levels. Only ethanol was used for ADH (Alcohol Dehydrogenize) blockade. Results Receiver operative curve characteristics showed that a serum methanol threshold level of 15mg/dl, instead of 25mg/dl, has a better sensitivity and rather the same specificity for predicting patient mortality. Conclusions With no fomepizloe and using conventional hemodialysis, lowering the threshold of methanol concentration for hemodialysis initiation, may save lives in acute methanol intoxication.
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Affiliation(s)
- Reza Hekmat
- Department of Nephrology, Ghaem Hospital, Mashhad, Iran
- Corresponding author: Reza Hekmat, Department of Nephrology, Ghaem Hospital, Mashhad, Iran. Tel.: +98-5118012829, Fax: +98-5118409693, E-mail:
| | | | - Bita Dadpour
- Department of Nephrology, Ghaem Hospital, Mashhad, Iran
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Joannidis M, Forni LG. Clinical review: timing of renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:223. [PMID: 21672279 PMCID: PMC3218965 DOI: 10.1186/cc10109] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Acute kidney injury is common in intensive care patients and continuous renal replacement therapy is the preferred treatment for this in most centres. Although these techniques have been adopted internationally, there remains significant variation with regard to their clinical application. This is particularly pertinent when one considers that the fundamental questions regarding any treatment, such as initiation, dose and length of treatment, remain a source of debate and have not as yet all been fully answered. In this narrative review we consider the timing of renal replacement therapy, highlighting the relative paucity of high quality data regarding this fundamental question. We examine the role of the usual biochemical criteria as well as conventional clinical indications for commencing renal replacement therapy together with the application of recent classification systems, namely RIFLE and AKIN. We discuss the potential role of biomarkers for acute kidney injury as predictors for the need for renal support and discuss commencing therapy for indications other than acute kidney injury.
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Affiliation(s)
- Michael Joannidis
- Medical Intensive Care Unit, Department of General Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
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Abstract
Patients who ingest toxic substances may require extracorporeal removal of the poisons or their toxic metabolites if native renal clearance is not sufficient because of acute kidney injury, acuity of symptoms, or burden of toxin. Here, a case is presented, and the literature on renal replacement therapy in the event of acute intoxication is reviewed. Extracorporeal therapy efficacy is examined in terms of the characteristics of the toxin (molecular size, charge, protein, or lipid binding); the patient (body habitus and volume of distribution); and the process (membrane effects on extraction ratios and sieving, role of blood, and dialysate flow rates). The choice of extracorporeal therapy and hemodialysis prescriptions for specific poisonings are discussed.
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Schoolwerth AC, Kaneko TM, Sedlacek M, Block CA, Remillard BD. CRITICAL CARE ISSUES FOR THE NEPHROLOGIST: Acid-base Disturbances in the Intensive Care Unit: Metabolic Acidosis. Semin Dial 2006; 19:492-5. [PMID: 17150049 DOI: 10.1111/j.1525-139x.2006.00211.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article will discuss metabolic acidosis and, to a lesser extent, metabolic alkalosis in the ICU setting. A classification and clinical approach will be the focus.
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Affiliation(s)
- Anton C Schoolwerth
- Section of Nephrology and Hypertension, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Louie JP, Peterson J. Not a basic case. Pediatr Emerg Care 2006; 22:461-3. [PMID: 16801854 DOI: 10.1097/01.pec.0000226027.55302.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jeffrey P Louie
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN, USA.
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