Treatment of lead and arsenic poisoning in anuric patients – a case report and narrative review of the literature

Abstract

Background Heavy metal poisoning can cause debilitating illness if left untreated, and its management in anuric patients poses challenges. Literature with which to guide clinical practice in this area is rather scattered. Case presentation We present a case of symptomatic lead and arsenic poisoning from use of Ayurvedic medicine in a 28-year-old man with end-stage kidney disease on chronic hemodialysis. We describe his treatment course with chelating agents and extracorporeal blood purification, and review the relevant literature to provide general guidance. Conclusion Cumulative clinical experience assists in identifying preferred chelators and modalities of extracorporeal blood purification when managing such patients. However, a larger body of real-world or clinical trial evidence is necessary to inform evidence-based guidelines for the management of heavy metal poisoning in anuric patients.

Controllable preparation and performance of bio-based poly(lactic acid-iminodiacetic acid) as sustained-release Pb2+ chelating agent

“…Importantly, this level of chelating capacity is suitable for a potential biomedical chelating agent as a treatment drug for chelating and removing lead ions in vivo because the threshold of lead poisoning that requires treatment is 10 μg·dL −1 ( Balasubramanian et al., 2020 ), and the corresponding dosage of small molecule chelating drugs is as low as 30 mg·kg −1 body weight per day ( Safi et al., 2019 ). This can avoid toxicity and adverse reactions caused by a high dosage of the chelating drugs ( Hsiao et al., 2019 ; Bradberry and Vale, 2009 ). In addition, the result also indicates that this Pb 2+ chelating capacity can be adjusted according to the need of the practical application.…”

Arsenic intoxication: general aspects and chelating agents

“…From World War I and particularly during World War II started the era of the use of chemical poisoning weapons, including toxic As compounds. Figure 1 reports the list of the most used As-based blister or vesicant, vomiting, and blood agents used as chemical weapons to date (Hoenig 2007). These very last warfare agents affect the body by being absorbed into the blood with the routes of inhalation or ingestion.…”

“…Severe eye irritation and damage to the upper respiratory tract occurs after 15 min at a Lewisite concentration of 0.01-0.03 mg/l. The relative toxicity of Lewisite during inhalation LCτ 50 is 1.3 mg/l/min (Goldman and Dacre 1989;Hoenig 2007;NIOSH 2011;Dyadchenko et al 2018).…”

“…Therefore DMSA should be preferred to DMPS (Kazantzis 2007). However, for the treatment of As poisoning in patients with anuria, DMPS is probably the safest and most effective chelating agent, while DMSA should not be used (Hsiao et al 2019).…”

Arsenic intoxication with renal failure managed with hemodialysis alone: A case report

“…In the setting of impaired renal excretion in CKD patients, the use of chelators can be deleterious since the arsenic mobilization induced by chelation can lead to aberrant organ deposition, particularly in the central nervous system. In renal failure, DMPS appears to be the treatment of choice because of its favorable properties allowing arsenic clearance during extracorporeal blood purification (8). Hemodialysis is also an effective tool in the treatment of arsenic intoxication as it leads to a considerable reduction in blood arsenic levels (9,10).…”