Management of a Severe Carbamazepine Overdose Using Albumin-Enhanced Continuous Venovenous Hemodialysis

Abstract

Carbamazepine intoxication is common in the pediatric population. Highly protein-bound, carbamazepine is not removed efficiently through conventional hemodialysis. We describe the use of albumin-enhanced continuous venovenous hemodialysis (CVVHD) in a 10-year-old girl who developed coma and respiratory depression due to an intentional carbamazepine overdose (peak drug level of 44.8 microg/ml; therapeutic range: 8-12 microg/ml). Without intervention, the half-life of drug elimination is 25 to 60 hours in patients who are naive to carbamazepine and 12 to 20 hours in children on chronic carbamazepine therapy. In contrast, with albumin-enhanced CVVHD, we observed a half-life of 7 to 8 hours. The patient recovered rapidly and was discharged from hospital <4 days from the time of ingestion with no complications or neurologic impairment. Because the cost-benefit analysis was also favorable relative to other therapeutic options, albumin-enhanced CVVHD may be the optimal treatment of toxic-level ingestion of carbamazepine.

Severe theophylline poisoning treated with continuous venovenous hemodialysis in a child

“…Albumin-enhanced dialysate has been reported in one case to treat a 6.5-month-old with valproic acid toxicity and a carbamazepine overdose in a 10-year-old 10,11 .Theophylline is approximately 50-60% protein bound and under normal conditions metabolized by the p450 enzyme in the liver 12 . For these reasons, we did not add albumin to the dialysate fluid.…”

Review of Extracorporeal Membrane Oxygenation and Dialysis-Based Liver Support Devices for the Use of Nephrologists

“…With regards to the dose of albumin, one case report showed that dialysate albumin as low as 1.85% resulted in similar removal of bilirubin when compared to 5% [71]. Finally, SPAD was reported to increase the elimination of albumin-bound drugs especially with the presence of AKI that would reduce their renal drug elimination [72,73,74]. The in-vitro study by Churchwell et al [74] was the most controlled as it compared the effect of various blood flows (180-270 mL/mn), dialysate flows (1-4 L/h), dialysate albumin concentrations (0, 2.5, and 5%), and dialyzers (1.5 m 2 polysulfone and 0.6 m 2 acrylonitrile 69) on the clearance of phenytoin, valproic acid, and carbamazepine.…”

Evaluation and Management of Acute Kidney Injury in Children

“…Acute drug intoxications and hyperammonemia secondary to inborn errors of metabolism are best treated with IHD since rapid drug removal is important to prevent morbidity and IHD is the most efficient RRT modality [122,123]. However, CRRT can be very effective for protein-bound drug removal if albumin is added to dialysis fluid and acute serum ammonia reduction in inborn errors of metabolism if higher than usual CRRT doses are used [124][125][126]. Finally, the particular center's expertise and nursing support availability should play a major role in determining the optimal RRT modality.…”