Dialysis and extracorporeal therapies for enhanced elimination of toxic ingestions and poisoning

Abstract

Poisoning and toxic ingestions cause significant morbidity and mortality worldwide. Extracorporeal therapies such as dialysis, hemoperfusion, and plasma exchange are selectively applied to patients with severe intoxications unresponsive to standard interventions and can be lifesaving. Extracorporeal therapies are a complex but fundamental aspect of the practice of nephrology.Without high-quality evidence to guide implementation, an understanding of toxicokinetics and the physiochemical principles of the enhanced elimination techniques is especially important. This review provides a comphrensive, userfriendly outline of the application of extracorporeal therapy in the poisoned patient.

Case report: Successful outcome of a young patient with rhabdomyolysis and shock caused by diquat poisoning

“…Meanwhile, underweight patients easily developed unfavorable mortality trends due to shock, which was probably related to malnutrition (13). Poison removal is critical to clinical treatment, but the intensity of hemoperfusion was still controversial and lack of systematic verification (14,15). A prospective study found that continuous venous hemofiltration (CVVH) combined with hemoperfusion could significantly improve the 90-day survival of paraquat poisoning (16).…”

Extrakorporale Eliminationsverfahren bei Vergiftungen

“…Durch Vergiftungen können die eliminationsbestimmenden Organfunktionen von Nieren und Leber beeinträchtigt und daher Dialyseverfahren zur Kompensation notwendig werden [1]. Darüber hinaus können extrakorporale Eliminationsverfahren, vor allem Dialyseverfahren, zur Entfernung toxischer Substanzen aus dem Blut bei lebensbedrohlichen Intoxikationen gerechtfertigt sein, wenn die Elimination der Noxe hierdurch signifikant gesteigert werden kann [2][3][4]. Für die individuelle Therapieentscheidung sollte dann nephrologische Expertise mit Unterstützung durch die Giftnotrufzentralen der Bundesländer angefragt, weshalb in diesem Artikel die Grundkenntnisse zu extrakorporalen Verfahren (▶Tab.…”

Hemodialysis treatment for poisoning patients in the emergency department

“…The higher the concentration of the free fraction of a drug and the lower the distribution volume in the body, the more likely that the drug can be removed by HD. HD is the first treatment option for poisonings caused by low molecular weight drugs that dissolve in water and can rapidly pass through HD membranes [2,4]. The main factors determining dialysis efficiency are membrane surface area, membrane permeability, blood flow rate, and dialysate flow rate.…”

“…High-flow hemodialyzers with a surface area of at least 1.5 m 2 should be used for emergency detoxification in poisoning patients, and the running dialysate and blood flow should be between 250 and 300 ml/min. The increased dialysate rate will get more efficiency from the increased blood flow [2].…”

“…Extracorporeal treatments may be preferred if patients are unresponsive to conventional treatment, the normal metabolic pathway of the drug is impaired, and extracorporeal treatment methods can remove the poison or metabolite that causes poisoning faster than endogenous mechanisms [2, 3]. Extracorporeal treatment methods include hemodialysis (HD), hemoperfusion (HP), hemofiltration, hemodiafiltration, plasmapheresis, liver support therapy (e.g., molecular adsorbent recirculating system [MARS], fractionated plasma separation and adsorption [FPSA], exchange transfusion, peritoneal dialysis, and extracorporeal membrane oxygenation [ECMO] [3]).…”