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Malvar G, Gunasekaran D, Mehr NV, Ishibe S, Moeckel G. Thrombotic Microangiopathy and Acute Tubular Injury After Diethylene Glycol Ingestion: A Kidney Biopsy Teaching Case. Kidney Med 2024; 6:100758. [PMID: 38304581 PMCID: PMC10831151 DOI: 10.1016/j.xkme.2023.100758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
We present a rare and unusual case of thrombotic microangiopathy (TMA) in a patient who ingested chafing fuel containing diethylene glycol. The patient showed a typical clinical course of initial gastrointestinal symptoms followed by acute kidney injury (AKI) and peripheral sensorimotor neuropathy. A kidney biopsy showed TMA and diffuse acute tubular injury. Diethylene glycol is widely used as a solvent in numerous consumer products, including brake fluid, antifreeze, chafing fuel, and artificial fog solutions. Diethylene glycol has been implemented in mass poisonings, and the incidence of AKI in diethylene glycol poisonings is linked to high-mortality rates. TMA, a pathologic lesion observed in a wide spectrum of diseases, is triggered by endothelial injury. Our case shows that TMA should be considered as a possible life-threatening complication in the setting of acute diethylene glycol poisoning. Direct toxic injury to endothelial cells by diethylene glycol is a possible mechanism. It is therefore plausible that patients with a genetic predisposition to endothelial injury may develop TMA following diethylene glycol exposure.
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Affiliation(s)
- Grace Malvar
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | | | | | - Shuta Ishibe
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Gilbert Moeckel
- Department of Pathology, Yale University School of Medicine, New Haven, CT
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de Almeida Araújo S, Faria BCD, Vasconcelos JC, da Cruz AF, de Souza VS, Wanderley DC, Simões-E-Silva AC. Renal toxicity caused by diethylene glycol: an overview. Int Urol Nephrol 2023; 55:2867-2875. [PMID: 37186212 DOI: 10.1007/s11255-023-03604-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
Diethylene glycol (DEG) is nephrotoxic, potentially resulting in high morbidity and mortality. Its main nephrotoxic by-product is diglycolic acid (DGA). This narrative overview summarizes selected literature with a focus on clinical findings, pathophysiology, diagnosis including morphological features of renal biopsies, and management. The kidney injury in DEG poisoning is secondary to proximal tubular necrosis caused by DGA. Marked vacuolization and edema of epithelial cells obstruct the lumen, reducing urine flow and, consequently, resulting in anuria and uremia. The clinical alterations due to DEG poisoning are dose-dependent. Patients may present with gastrointestinal symptoms and anion gap metabolic acidosis, followed by renal failure, and, later, encephalopathy and neuropathy. Although this three-phase pattern has been described, signs and symptoms may be overlapping. Data about DEG intoxication is scarce. Sometimes the diagnosis is challenging. The management includes supportive care, gastric decontamination, correction of acid-base disorders, and hemodialysis. The understanding of the metabolic processes related to DEG poisoning may contribute to its management, preventing death, serious sequels, or irreversible lesions.
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Affiliation(s)
- Stanley de Almeida Araújo
- Instituto de Nefropatologia, Belo Horizonte, MG, Brasil
- Centro de Microscopia Eletrônica, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Bárbara Caroline Dias Faria
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais Belo Horizonte, Avenida Alfredo Balena, 190, 2o andar, sala 281, Bairro Santa Efigênia, MG, CEP 30130-100, Brasil
| | - Júlia Cunha Vasconcelos
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais Belo Horizonte, Avenida Alfredo Balena, 190, 2o andar, sala 281, Bairro Santa Efigênia, MG, CEP 30130-100, Brasil
| | - Aniel Feitosa da Cruz
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais Belo Horizonte, Avenida Alfredo Balena, 190, 2o andar, sala 281, Bairro Santa Efigênia, MG, CEP 30130-100, Brasil
| | - Vitor Santos de Souza
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais Belo Horizonte, Avenida Alfredo Balena, 190, 2o andar, sala 281, Bairro Santa Efigênia, MG, CEP 30130-100, Brasil
| | - David Campos Wanderley
- Instituto de Nefropatologia, Belo Horizonte, MG, Brasil
- Centro de Microscopia Eletrônica, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Ana Cristina Simões-E-Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais Belo Horizonte, Avenida Alfredo Balena, 190, 2o andar, sala 281, Bairro Santa Efigênia, MG, CEP 30130-100, Brasil.
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Reed KJ, Freeman DT, Landry GM. Diethylene glycol and its metabolites induce cell death in SH-SY5Y neuronal cells in vitro. Toxicol In Vitro 2021; 75:105196. [PMID: 34022404 DOI: 10.1016/j.tiv.2021.105196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/04/2021] [Accepted: 05/15/2021] [Indexed: 01/07/2023]
Abstract
Diethylene glycol (DEG) intoxication results in metabolic acidosis, renal and hepatic dysfunction, and late-stage neurotoxicity. Though the renal and hepatic toxicity of DEG and its metabolites 2-hydroxyethoxyacetic acid (2-HEAA) and diglycolic acid (DGA) have been well characterized, the resultant neurotoxicity has not. SH-SY5Y neuroblastoma cells were incubated with all 3 compounds at increasing concentrations for 24, 48, or 120 h. At all 3 time points, 50 mmol/L DGA and 100 mmol/L DEG showed significant Annexin V and propidium iodide (PI) staining with additional concentrations showing similar staining patterns at 24 h (100 mmol/L DGA) and 48 h (50 mmol/L DEG, 100 mmol/L DGA). Only the 200 mmol/L 2-HEAA concentration induced SH-SY5Y cell death. Interestingly at 24 and 48 h, 100 mmol/L DEG induced significant increases in apoptotic cell death markers, which progressed to necrosis at 120 h. Similar to DEG, 50 mmol/L DGA induced significant increases in SH-SY5Y cell apoptosis and necrosis markers at both 24 and 48 h. As expected, high DGA concentrations (100 mmol/L) at 120 h induced significant SH-SY5Y cell necrosis with no apoptosis detected. However, at 120 h lower DGA concentrations (20 mmol/L) significantly increased oligonucleosome formation alone and in combination with 2-HEAA or DEG. Taken together, these results indicate that DGA and DEG at threshold concentrations induce neurotoxicity in SH-SY5Y cells.
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Affiliation(s)
- Kristi J Reed
- MCPHS University, School of Pharmacy, Department of Pharmaceutical Sciences, Boston, MA 02115, United States
| | - Dylan T Freeman
- MCPHS University, School of Pharmacy, Department of Pharmaceutical Sciences, Boston, MA 02115, United States
| | - Greg M Landry
- MCPHS University, School of Pharmacy, Department of Pharmaceutical Sciences, Boston, MA 02115, United States.
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