Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup

Continuous Venovenous Hemofiltration as a Rescue Therapy for Severe Acetaminophen Toxicity in a Toddler

“…The group suggested to start RRT in acetaminophen toxicity in the presence of declining neurological status (encephalopathy or coma) with depression of autonomic control of circulatory or respiratory systems; severe metabolic acidosis (pH <7.1) refractory to supportive treatment; and acetaminophen blood levels >1,000 mg/L and NAC therapy has not been initiated. 12 The index child was started on CRRT (CVVH) as there was no improvement in clinical and biochemical status despite treatment with NAC, presence of severe liver dysfunction, small size (10 kg) of the child, and availability of CRRT. There are only few case reports among adults with massive acetaminophen toxicity where HD or CRRT was used as a rescue measure with a favorable outcome.…”

“…The administration of NAC repletes endogenous GSH stores and promotes conjugation of NAPQI to nontoxic metabolites, thereby decreasing the toxic effects of NAPQI. [12][13][14] The signs and symptoms of acetaminophen toxicity occur in the four progressive phases. In phase 1 (lasts for 0.5-24 hours), there is anorexia, nausea, vomiting, diaphoresis, and lethargy.…”

“…During phase 4 (lasts for 4-14 days), the patient will either die ofmultiorgan failure or recover from liver failure. 12,15 While managing a child with acetaminophen toxicity, levels are obtained at 4 and 8 hours of ingestion and plotted on Rumack-Matthew nomogram and if levels cross the treatment line, NAC is started. 16 Sometimes with ingestion of massive doses of acetaminophen, the standard dose of NAC does not lead to improvement because NAC reacts in 1:1 fashion with NAPQI and with larger overdose, there is more NAPQI than NAC.…”

“…2 If there is no improvement, extracorporeal therapies such as hemodialysis (HD), sustained low efficiency dialysis (SLED), continuous venovenous hemofiltration (CVVH), high-volume plasma exchange (PLEX), and molecular adsorbent recirculating system (MARS) can be used as rescue measures. [3][4][5][6][7][8][9][10][11][12] Here, we present an 18-month-old male infant who had presented with fulminant liver failure following accidental ingestion of acetaminophen. CVVH was used as a rescue therapy, which led to complete recovery.…”

Massive Acetaminophen Overdose

“…Hemodialysis is recommended for patients with extreme plasma acetaminophen concentrations (> 200 µg/mL plasma at four hours post-ingestion) or displaying symptoms of mitochondrial dysfunction such as elevated lactate levels and acidosis [9,10]. CRRT is also suggested in severe cases in which patients display neurological, respiratory, or circulatory malfunctioning (encephalopathy or coma) as our patient did [11].…”