Skip to main content
SpringerLink
Log in

Use of extracorporeal therapies to treat life-threatening intoxications

  • Educational Review
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Toxic ingestions are a significant cause of pediatric morbidity and mortality, with some requiring extracorporeal removal for therapy. Given the emergent and life-threatening nature of such scenarios, it is paramount that clinicians caring for intoxicated children be familiar with the subject. This review summarizes the following: (a) the properties of a substance which lend it amenable to removal; (b) the current extracorporeal treatment modalities available for such removal (of which hemodialysis is typically the ideal choice); (c) an introduction and framework to use a quick reference guide from the Extrip organization, which has a website available to guide clinicians’ rapid decisions; and (d) new membranes/approaches that may optimize clearance of certain intoxications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, Rivers LJ, Pham NPT, Ryan ML (2020) 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila) 58:1360–1541

    Article  PubMed  Google Scholar 

  2. Raina R, Grewal MK, Blackford M, Symons JM, Somers MJ, Licht C, Basu RK, Sethi SK, Chand D, Kapur G (2019) Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup. Pediatr Nephrol 34:2427–2448

    Article  PubMed  Google Scholar 

  3. Tyagi PK, Winchester JF, Feinfeld DA (2008) Extracorporeal removal of toxins. Kidney Int 74:1231–1233

    Article  CAS  PubMed  Google Scholar 

  4. Mirrakhimov AE, Barbaryan A, Gray A, Ayach T (2016) The role of renal replacement therapy in the management of pharmacologic poisonings. Int J Nephrol 2016

  5. Levy G, Yaffe SJ (1974) Relationship between dose and apparent volume of distribution of salicyiate in children. Pediatr Res 8:365–365

    Article  Google Scholar 

  6. Øie S (1986) Drug distribution and binding. J Clin Pharmacol 26:583–586

    Article  PubMed  Google Scholar 

  7. Mansoor A, Mahabadi N (2022) Volume of distribution. StatPearls [Internet]. StatPearls Publishing, Treasure Island, FL. https://www.ncbi.nlm.nih.gov/books/NBK545280/

  8. Meyer TW (2012) The removal of protein-bound solutes by dialysis. J Ren Nutr 22:203–206

    Article  CAS  PubMed  Google Scholar 

  9. Dudley MN, Shyu W, Nightingale C, Quintiliani R (1986) Effect of saturable serum protein binding on the pharmacokinetics of unbound cefonicid in humans. Antimicrob Agents Chemother 30:565–569

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Allawati H, Dallas L, Nair S, Palmer J, Thaikandy S, Hutchison C (2020) A pharmacokinetic study comparing the clearance of vancomycin during haemodialysis using medium cut-off membrane (theranova) and high-flux membranes (revaclear). Toxins 12:317

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Weidhase L, Haussig E, Haussig S, Kaiser T, de Fallois J, Petros S (2019) Middle molecule clearance with high cut-off dialyzer versus high-flux dialyzer using continuous veno-venous hemodialysis with regional citrate anticoagulation: a prospective randomized controlled trial. PLoS One 14:e0215823

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Amyot S-L, Leblanc M, Thibeault Y, Geadah D, Cardinal J (1999) Myoglobin clearance and removal during continuous venovenous hemofiltration. Intensive Care Med 25:1169–1172

    Article  CAS  PubMed  Google Scholar 

  13. Ghannoum M, Hoffman RS, Gosselin S, Nolin TD, Lavergne V, Roberts DM (2018) Use of extracorporeal treatments in the management of poisonings. Kidney Int 94:682–688

    Article  PubMed  Google Scholar 

  14. De Pont AC (2007) Extracorporeal treatment of intoxications. Curr Opin Crit Care 13:668–673

    Article  PubMed  Google Scholar 

  15. Mégarbane B (2010) Treatment of patients with ethylene glycol or methanol poisoning: focus on fomepizole. Open Access Emerg Med 2:67

    Article  PubMed  PubMed Central  Google Scholar 

  16. Warady BA, Schaefer F, Alexander SR (2011) Pediatric dialysis. Third edition. Springer Nature Switzerland, Cham

  17. Churchill BM, Patri P (2021) The nitty-gritties of Kt/Vurea calculations in hemodialysis and peritoneal dialysis. Indian J Nephrol 31:97

    Article  PubMed  PubMed Central  Google Scholar 

  18. Kane SL, Constantiner M, Staubus AE, Meinecke CD, Sedor JR (2000) High-flux hemodialysis without hemoperfusion is effective in acute valproic acid overdose. Ann Pharmacother 34:1146–1151

    Article  CAS  PubMed  Google Scholar 

  19. Sikma M, Van den Broek M, Meulenbelt J (2012) Increased unbound drug fraction in acute carbamazepine intoxication: suitability and effectiveness of high-flux haemodialysis. Intensive Care Med 38:916–917

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Vijayan A, Palevsky PM (2012) Dosing of renal replacement therapy in acute kidney injury. Am J Kidney Dis 59:569–576

    Article  PubMed  PubMed Central  Google Scholar 

  21. Spinale JM, Laskin BL, Sondheimer N, Swartz SJ, Goldstein SL (2013) High-dose continuous renal replacement therapy for neonatal hyperammonemia. Pediatr Nephrol 28:983–986

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ahmed S, Kaplan A (2020) Therapeutic plasma exchange using membrane plasma separation. Clin J Am Soc Nephrol 15:1364–1370

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Ward DM (2011) Conventional apheresis therapies: a review. J Clin Apher 26:230–238

    Article  PubMed  Google Scholar 

  24. Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, Sarode R, Schwartz J, Weinstein R, Shaz BH (2010) Guidelines on the use of therapeutic apheresis in clinical practice—evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 25:83–177

    Article  PubMed  Google Scholar 

  25. Schutt RC, Ronco C, Rosner MH (2012) The role of therapeutic plasma exchange in poisonings and intoxications. Semin Dial 25:201–206

    Article  PubMed  Google Scholar 

  26. Peszynski P, Klammt S, Peters E, Mitzner S, Stange J, Schmidt R, Peszynski P, Klammt S, Peters E, Mitzner S (2002) Albumin dialysis: single pass vs. recirculation (MARS). Liver 22:40–42

    Article  CAS  PubMed  Google Scholar 

  27. Vilay AM, Mueller BA, Haines H, Alten JA, Askenazi DJ (2010) Treatment of methotrexate intoxication with various modalities of continuous extracorporeal therapy and glucarpidase. Pharmacotherapy 30:111

    Article  PubMed  Google Scholar 

  28. Kıhtır HS, Yıldırım HM, Yeşilbaş O, Duramaz BB, Şevketoğlu E (2016) Single-pass albumin dialysis in a child aged six months with phenobarbital poisoning. Turk Arch Pediatr 51:228

    Article  Google Scholar 

  29. Chung YK, Chang KY, Park HS, Kim MH, Lee KM, Lim TS, Kim HW (2014) Severe carbamazepine intoxication unresponsive to albumin-enhanced continuous venovenous hemodiafiltration with low dialysate flow. Hemodial Int 18:551–555

    Article  PubMed  Google Scholar 

  30. Koivusalo AM, Yildirim Y, Vakkuri A, Lindgren L, Höckerstedt K, Isoniemi H (2003) Experience with albumin dialysis in five patients with severe overdoses of paracetamol. Acta Anaesthesiol Scand 47:1145–1150

    Article  CAS  PubMed  Google Scholar 

  31. McIntyre CW, Fluck RJ, Freeman JG, Lambie SH (2002) Use of albumin dialysis in the treatment of hepatic and renal dysfunction due to paracetamol intoxication. Nephrol Dial Transplant 17:316–317

    Article  PubMed  Google Scholar 

  32. Pichon N, François B, Clavel M, Vignon P, Chevreuil C, Michel Gaulier J (2006) Albumin dialysis: a new therapeutic alternative for severe diltiazem intoxication. Clin Toxicol 44:195–196

    Article  Google Scholar 

  33. Dobisova A, Vavrinec P, Vavrincova-Yaghi D, Gebhardtova A, Henning RH, Yaghi A (2021) Case report: enhanced diazepam elimination with the molecular adsorbents recirculating system (MARS) in severe autointoxication: a survival case report. Front Med 8:189

    Article  Google Scholar 

  34. Covic A, Goldsmith DJ, Gusbeth-Tatomir P, Volovat C, Dimitriu AG, Cristogel F, Bizo A (2003) Successful use of molecular absorbent regenerating system (MARS) dialysis for the treatment of fulminant hepatic failure in children accidentally poisoned by toxic mushroom ingestion. Liver Int 23:21–27

    Article  CAS  PubMed  Google Scholar 

  35. Prokurat S, Grenda R, Lipowski D, Kaliciński P, Migdal M, Prokurat S, Grenda R, Lipowski D, Kaliciński P, Migdal M (2002) MARS procedure as a bridge to combined liver–kidney transplantation in severe chromium–copper acute intoxication: a paediatric case report. Liver 22:76–77

    Article  PubMed  Google Scholar 

  36. Sen S, Ratnaraj N, Davies NA, Mookerjee RP, Cooper CE, Patsalos PN, Williams R, Jalan R (2003) Treatment of phenytoin toxicity by the molecular adsorbents recirculating system (MARS). Epilepsia 44:265–267

    Article  PubMed  Google Scholar 

  37. Korsheed S, Selby NM, Fluck RJ (2007) Treatment of severe theophylline poisoning with the molecular adsorbent recirculating system (MARS). Nephrol Dial Transplant 22:969–970

    Article  PubMed  Google Scholar 

  38. Wittebole X, Hantson P (2011) Use of the molecular adsorbent recirculating system (MARS™) for the management of acute poisoning with or without liver failure. Clin Toxicol 49:782–793

    Article  CAS  Google Scholar 

  39. Lavergne V, Nolin TD, Hoffman RS, Roberts D, Gosselin S, Goldfarb DS, Kielstein JT, Mactier R, Maclaren R, Mowry JB (2012) The EXTRIP (extracorporeal treatments in poisoning) workgroup: guideline methodology. Clin Toxicol 50:403–413

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, 1600 5Th Ave S, Park Place Suite 202, Birmingham, AL, 35233, USA

    Kyle Deville & David Askenazi

  2. Department of Emergency Medicine, Division of Toxicology, University of Virginia, Charlottesville, USA

    Nathan Charlton

Authors
  1. Kyle Deville
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nathan Charlton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David Askenazi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Askenazi.

Ethics declarations

Conflict of interest

For full disclosure, we provide here an additional list of other author commitments and funding sources that are not directly related to this study: David J Askenazi is a consultant for Baxter, Nuwellis, Medtronic Bioporto, and Seastar. His institution receives grant funding for education and research that is not related to this project from NIH, Baxter, Nuwellis, Medtronic, Bioporto, and Seastar. He has patents pending on inventions to improve the kidney care of neonates. He is the Founder and Chief Scientific Officer for Zorro-Flow Inc. Kyle Deville is on the T32 DK007545 NIH-NRSA funded training grant 'Interdisciplinary Training in Kidney-Related Research'.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Multiple choice answers: 1. c; 2. d; 3. False; 4. b

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Deville, K., Charlton, N. & Askenazi, D. Use of extracorporeal therapies to treat life-threatening intoxications. Pediatr Nephrol 39, 105–113 (2024). https://doi.org/10.1007/s00467-023-05937-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-023-05937-7

Keywords

Search

Navigation