Extracorporeal Removal of Poisons and Toxins

Abstract

Extracorporeal therapies have been used to remove toxins from the body for over 50 years and have a greater role than ever before in the treatment of poisonings. Improvements in technology have resulted in increased efficacy of removing drugs and other toxins with hemodialysis, and newer extracorporeal therapy modalities have expanded the role of extracorporeal supportive care of poisoned patients. However, despite these changes, for at least the past three decades the most frequently dialyzed poisons remain salicylates, toxic alcohols, and lithium; in addition, the extracorporeal treatment of choice for therapeutic removal of nearly all poisonings remains intermittent hemodialysis. For the clinician, consideration of extracorporeal therapy in the treatment of a poisoning depends upon the characteristics of toxins amenable to extracorporeal removal (e.g., molecular mass, volume of distribution, protein binding), choice of extracorporeal treatment modality for a given poisoning, and when the benefit of the procedure justifies additive risk. Given the relative rarity of poisonings treated with extracorporeal therapies, the level of evidence for extracorporeal treatment of poisoning is not robust; however, extracorporeal treatment of a number of individual toxins have been systematically reviewed within the current decade by the Extracorporeal Treatment in Poisoning workgroup, which has published treatment recommendations with an improved evidence base. Some of these recommendations are discussed, as well as management of a small number of relevant poisonings where extracorporeal therapy use may be considered.

Mortality and associated risk factors in patients with severe methanol or ethylene glycol poisoning treated with dialysis: a retrospective cohort study

“…2 Only patients with ethylene glycol poisoning were included. 3 For male patients. 4 For female patients.…”

“…Furthermore, oxalic acid and glycolic acid induce tissue toxicity and metabolic acidosis. [3][4][5] Patients with voluntary or inadvertent MET or EG poisoning often present with analogous symptoms that may resemble those of other common acute illnesses such as diabetic ketoacidosis or sepsis. Furthermore, the laboratory tests needed to diagnose MET or EG poisoning may not be immediately available, leading to potential delays in care.…”

Unintentional Ethylene Glycol Poisoning in an Adolescent

“…It is metabolized in the liver first to glycolaldehyde by the action of alcohol dehydrogenase using nicotinamide adenine dinucleotide (NAD) in the process. Glycolaldehyde is further metabolized to glycolic acid, glyoxylic acid, and oxalic acid by the process of oxidation, as seen in Figure 1 [3][4][5][6][7]. Although ethylene glycol causes an increased osmolality and therefore an increased osmotic gap, it neither causes acidosis nor an increased anion gap by itself.…”

Plasma Exchange in Acute and Acute on Chronic Liver Failure

“…TPE can clear pro-and anti-inflammatory cytokines, growth factors, beneficial immunoglobulins, coagulation factors, antibiotics, and toxins. [93][94][95] Patients with liver failure are distinctly different as compared with other immune-mediated diseases. The liver has a unique potential to regenerate, and there is a lack of pathogenic autoantibodies compared with other immune-mediated conditions.…”

“…The liver has a unique potential to regenerate, and there is a lack of pathogenic autoantibodies compared with other immune-mediated conditions. [91][92][93][94][95][96] TPE can clear the proinflammatory cytokines; however, at the same time, it nonselectively also removes the beneficial growth factors and anti-inflammatory cytokines predisposing the patients to infections and secondary organ failures. There are limited studies in patients with liver failure evaluating the ideal exchange volume and intensity of therapy.…”