1
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Boehm T, Martin-Higueras C, Friesser E, Zitta C, Wallner S, Walli A, Kovacevic K, Hubmann H, Klavins K, Macheroux P, Hoppe B, Jilma B. Simple, fast and inexpensive quantification of glycolate in the urine of patients with primary hyperoxaluria type 1. Urolithiasis 2023; 51:49. [PMID: 36920530 PMCID: PMC10017573 DOI: 10.1007/s00240-023-01426-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023]
Abstract
In primary hyperoxaluria type 1 excessive endogenous production of oxalate and glycolate leads to increased urinary excretion of these metabolites. Although genetic testing is the most definitive and preferred diagnostic method, quantification of these metabolites is important for the diagnosis and evaluation of potential therapeutic interventions. Current metabolite quantification methods use laborious, technically highly complex and expensive liquid, gas or ion chromatography tandem mass spectrometry, which are available only in selected laboratories worldwide. Incubation of ortho-aminobenzaldehyde (oABA) with glyoxylate generated from glycolate using recombinant mouse glycolate oxidase (GO) and glycine leads to the formation of a stable dihydroquinazoline double aromatic ring chromophore with specific peak absorption at 440 nm. The urinary limit of detection and estimated limit of quantification derived from eight standard curves were 14.3 and 28.7 µmol glycolate per mmol creatinine, respectively. High concentrations of oxalate, lactate and L-glycerate do not interfere in this assay format. The correlation coefficient between the absorption and an ion chromatography tandem mass spectrometry method is 93% with a p value < 0.00001. The Bland-Altmann plot indicates acceptable agreement between the two methods. The glycolate quantification method using conversion of glycolate via recombinant mouse GO and fusion of oABA and glycine with glyoxylate is fast, simple, robust and inexpensive. Furthermore this method might be readily implemented into routine clinical diagnostic laboratories for glycolate measurements in primary hyperoxaluria type 1.
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Affiliation(s)
- Thomas Boehm
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | | | - Eva Friesser
- Institute of Biochemistry, Graz University of Technology, Graz, Austria
| | - Clara Zitta
- Institute of Biochemistry, Graz University of Technology, Graz, Austria
| | - Silvia Wallner
- Institute of Biochemistry, Graz University of Technology, Graz, Austria
| | - Adam Walli
- Laboratory Dr. Wisplinghoff, Forensic and Clinical Toxicology, Cologne, Germany
| | - Katarina Kovacevic
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Holger Hubmann
- Department of Paediatrics and Adolescent Medicine, Division of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Kristaps Klavins
- Rudolfs Cimdins Riga Biomaterials Innovations and Development Centre, Institute of General Chemical Engineering, Faculty of Materials Science and Applied Chemistry, Riga Technical University, Riga, Latvia
| | - Peter Macheroux
- Institute of Biochemistry, Graz University of Technology, Graz, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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2
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Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, Mégarbane B, Hassanian-Moghaddam H, Rif M, Kallab S, Bird S, Wood DM, Roberts DM, Anseeuw K, Berling I, Bouchard J, Bunchman TE, Calello DP, Chin PK, Doi K, Galvao T, Goldfarb DS, Hoegberg LCG, Kebede S, Kielstein JT, Lewington A, Li Y, Macedo EM, MacLaren R, Mowry JB, Nolin TD, Ostermann M, Peng A, Roy JP, Shepherd G, Vijayan A, Walsh SJ, Wong A, Yates C. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2023; 27:56. [PMID: 36765419 PMCID: PMC9921105 DOI: 10.1186/s13054-022-04227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/18/2022] [Indexed: 02/12/2023] Open
Abstract
Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.
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Affiliation(s)
- Marc Ghannoum
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada ,grid.137628.90000 0004 1936 8753Nephrology Division, NYU Langone Health, NYU Grossman School of Medicine, New York, NY USA ,grid.5477.10000000120346234Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Gosselin
- grid.420748.d0000 0000 8994 4657Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC Canada ,grid.86715.3d0000 0000 9064 6198Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada ,Centre Antipoison du Québec, Quebec, QC Canada
| | - Robert S. Hoffman
- grid.137628.90000 0004 1936 8753Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Valery Lavergne
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada
| | - Bruno Mégarbane
- grid.411296.90000 0000 9725 279XDepartment of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Hossein Hassanian-Moghaddam
- grid.411600.2Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Siba Kallab
- grid.411323.60000 0001 2324 5973Department of Internal Medicine-Division of Nephrology, Lebanese American University - School of Medicine, Byblos, Lebanon
| | - Steven Bird
- Department of Emergency Medicine, U Mass Memorial Health, U Mass Chan Medical School, Worcester, MA USA
| | - David M. Wood
- grid.13097.3c0000 0001 2322 6764Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, and Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Darren M. Roberts
- grid.430417.50000 0004 0640 6474New South Wales Poisons Information Centre, Sydney Children’s Hospitals Network, Westmead, NSW Australia ,grid.413249.90000 0004 0385 0051Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW Australia
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Roberts DM, Hoffman RS, Brent J, Lavergne V, Hovda KE, Porter WH, McMartin KE, Ghannoum M. The serum glycolate concentration: its prognostic value and its correlation to surrogate markers in ethylene glycol exposures. Clin Toxicol (Phila) 2022; 60:798-807. [PMID: 35323087 DOI: 10.1080/15563650.2022.2049811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Ethylene glycol poisoning manifests as metabolic acidemia, acute kidney injury and death. The diagnosis and treatment depend on history and biochemical tests. Glycolate is a key toxic metabolite that impacts prognosis, but assay results are not widely available in a clinically useful timeframe. We quantitated the impact of serum glycolate concentration for prognostication and evaluated whether more readily available biochemical tests are acceptable surrogates for the glycolate concentration. OBJECTIVES The objectives of this study are to 1) assess the prognostic value of the initial glycolate concentration on the occurrence of AKI or mortality in patients with ethylene glycol exposure (prognostic study); 2) identify surrogate markers that correlate best with glycolate concentrations (surrogate study). METHODS A systematic review of the literature was performed using Medline/PubMed, EMBASE, Cochrane library, conference proceedings and reference lists. Human studies reporting measured glycolate concentrations were eligible. Glycolate concentrations were related to categorical clinical outcomes (acute kidney injury, mortality), and correlated with continuous surrogate biochemical measurements (anion gap, base excess, bicarbonate concentration and pH). Receiver operating characteristic curves were constructed to calculate the positive predictive values and the negative predictive values of the threshold glycolate concentrations that predict acute kidney injury and mortality. Further, glycolate concentrations corresponding to 100% negative predictive value for mortality and 95% negative predictive value for acute kidney injury were determined. RESULTS Of 1,531 articles identified, 655 were potentially eligible and 32 were included, reflecting 137 cases from 133 patients for the prognostic study and 154 cases from 150 patients for the surrogate study. The median glycolate concentration was 11.2 mmol/L (85.1 mg/dL, range 0-38.0 mmol/L, 0-288.8 mg/dL), 93% of patients were treated with antidotes, 80% received extracorporeal treatments, 49% developed acute kidney injury and 13% died. The glycolate concentration best predicting acute kidney injury was 12.9 mmol/L (98.0 mg/dL, sensitivity 78.5%, specificity 88.1%, positive predictive value 86.4%, negative predictive value 80.9%). The glycolate concentration threshold for a 95% negative predictive value for acute kidney injury was 6.6 mmol/L (50.2 mg/dL, sensitivity 96.9%, specificity 62.7%). The glycolate concentration best predicting mortality was 19.6 mmol/L (149.0 mg/dL, sensitivity 61.1%, specificity 81.4%, positive predictive value 33.3%, negative predictive value 93.2%). The glycolate concentration threshold for a 100% negative predictive value for mortality was 8.3 mmol/L (63.1 mg/dL, sensitivity 100.0%, specificity 35.6%). The glycolate concentration correlated best with the anion gap (R2 = 0.73), followed by bicarbonate (R2 = 0.57), pH (R2 = 0.50) and then base excess (R2 = 0.25), while there was no correlation between the glycolate and ethylene glycol concentration (R2 = 0.00). These data can assist clinicians in planning treatments such as extracorporeal treatments and prognostication. Potentially, they may also provide some reassurance regarding when extracorporeal treatments can be delayed while awaiting the results of further testing in patients in whom ethylene glycol poisoning is suspected but not yet confirmed. CONCLUSIONS This systematic review demonstrates that the glycolate concentration predicts mortality (unlikely if <8 mmol/L [61 mg/dL]). The anion gap is a reasonable surrogate measurement for glycolate concentration in the context of ethylene glycol poisoning. The findings are mainly based on published retrospective data which have various limitations. Further prospective validation studies are of interest.
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Affiliation(s)
- Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NY, USA
| | - Jeffrey Brent
- Departments of Medicine and Emergency Medicine, University of Colorado, School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - William H Porter
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center Lexington, KY, USA
| | | | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
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4
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Kuusela E, Järvisalo MJ, Hellman T, Uusalo P. Mortality and associated risk factors in patients with severe methanol or ethylene glycol poisoning treated with dialysis: a retrospective cohort study. J Int Med Res 2022; 50:3000605221081427. [PMID: 35209742 PMCID: PMC8891871 DOI: 10.1177/03000605221081427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the initial clinical course and data on 90-day mortality in adults with methanol (MET) or ethylene glycol (EG) poisoning treated with dialysis. Methods Data on patient demographics and clinical parameters at intensive care unit (ICU) admission and for the first 24 hours after dialysis initiation were collected, and 90-day outcome data were collected for patients with MET (n = 15) or EG (n = 13) poisoning treated with dialysis in this retrospective cohort study. Results In univariate analysis, patients with EG poisoning were older and they had lower hourly urine output during the first 24 hours after the initiation of dialysis. Six (46%) patients with MET poisoning and three (20%) patients with EG poisoning died within 90 days of ICU admission. A larger anion gap and lower pH, bicarbonate levels, base excess, and Glasgow Coma Scale scores on admission, as well as the need for mechanical ventilation, were associated with 90-day mortality. Conclusions Metabolic acidosis, a large anion gap, and an altered mental status on admission appear to be associated with mortality in MET or EG poisoning, and EG poisoning may be linked to lower urine output.
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Affiliation(s)
- Emma Kuusela
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko J Järvisalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
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5
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Cohen ET, Su MK, Biary R, Hoffman RS. Distinguishing between toxic alcohol ingestion vs alcoholic ketoacidosis: how can we tell the difference? Clin Toxicol (Phila) 2021; 59:715-720. [DOI: 10.1080/15563650.2020.1865542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Emily T. Cohen
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Mark K. Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications. Biomarkers 2020; 25:112-125. [PMID: 32011177 DOI: 10.1080/1354750x.2020.1725787] [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] [Indexed: 01/16/2023]
Abstract
In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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7
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Lim SK, Yoo J, Kim H, Kim W, Shim I, Yoon BI, Kim P, DO Yu S, Eom IC. Acute and 28-Day Repeated Inhalation Toxicity Study of Glycolic Acid in Male Sprague-Dawley Rats. In Vivo 2020; 33:1507-1519. [PMID: 31471399 DOI: 10.21873/invivo.11631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The use of glycolic acid is present in a variety of consumer products, including medicines, cleaners, cosmetics, and paint strippers. It has recently led to concerns about toxicity from inhalation exposure. Herein, the pulmonary toxicity of glycolic acid was investigated in rats. MATERIALS AND METHODS We conducted acute (~458 mg/m3) and sub-acute (~49.5 mg/m3) inhalation tests to identify the potential toxicities of glycolic acid. RESULTS Inhalation exposure to glycolic acid in the acute and subacute inhalation tests did not cause any specific changes in clinical examinations, including body weight, organ weight, hematology, serum biochemistry, and histopathology. The polymorphonuclear neutrophils (PMNs) and inflammatory cytokines in Bronchoalveolar lavage fluid (BALF) increased in rats exposed to single and repeated inhalations. In the sub-acute test, the changes induced by glycolic acid were minor or returned to normal during the recovery period. CONCLUSION The No Observed Adverse Effect Concentration (NOAEC) for the nasal and pulmonary toxicity of glycolic acid was determined to be over 50 mg/m3 at the end of a 28-day inhalation test in male rats.
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Affiliation(s)
- Seong Kwang Lim
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Jean Yoo
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Haewon Kim
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Woong Kim
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Ilseob Shim
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Byung-Il Yoon
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, Republic of Korea
| | - Pilje Kim
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Seung DO Yu
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Ig-Chun Eom
- Environmental Health Research Department, National Institute of Environmental Research, Incheon, Republic of Korea
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8
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview. Biomarkers 2019; 25:9-19. [PMID: 31735069 DOI: 10.1080/1354750x.2019.1694994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute intoxications account for a significant proportion of the patient population in intensive care units and sedative medications, ethanol, illicit drugs, inhalable poisons and mixed intoxications are the most common causes. The aim of this article is to describe biomarkers for screening and diagnosis of acute intoxications in critically ill patients. For this purpose, a survey of the relevant literature was conducted, and guidelines, case reports, expert assessments, and scientific publications were reviewed. In critical care, it should always be attempted to identify and quantify the poison or toxin with the assistance of enzyme immunoassay (EIA), chromatography, and mass spectrometry techniques and this section is critically appraised in this publication. The principles for anion gap, osmol gap and lactate gap and their usage in intoxications is shown. Basic rules in test methodology and pre-analytics are reviewed. Biomarkers in general are presented in part one and biomarkers for specific intoxications including ethanol, paracetamol, cardiovascular drugs and many others are presented in part two of these publications.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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9
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Stevens JS, Al-Awqati Q. Lactate dehydrogenase 5: identification of a druggable target to reduce oxaluria. J Clin Invest 2019; 129:2201-2204. [PMID: 31107247 DOI: 10.1172/jci128709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Excessive excretion of oxalate in the urine results in the formation of calcium oxalate crystals and subsequent kidney stone formation. Severe forms of hyperoxaluria, including genetic forms and those that result from ethylene glycol poisoning, can result in end-stage renal disease. Therapeutic interventions are limited and often rely on dietary intervention. In this issue of the JCI, Le Dudal and colleagues demonstrate that the lactate dehydrogenase 5 inhibitor (LDH5) stiripentol reduces urinary oxalate excretion. Importantly, stiripentol treatment of a single individual with primary hyperoxaluria reduced the urinary oxalate excretion. Together, these results support further evaluation of LDH5 as a therapeutic target for hyperoxaluria.
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[Acute intoxications: markers for screening, diagnosis and therapy monitoring]. Med Klin Intensivmed Notfmed 2019; 114:302-312. [PMID: 30944942 DOI: 10.1007/s00063-019-0566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/21/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Abstract
Acute poisonings account for a significant proportion of the patient population presenting to intensive care units, whereby mixed drug overdoses and prescription drug overdoses predominate. The aim of this article was to describe indications for screening, diagnosis and therapy monitoring in acute overdoses in the intensive care unit. To conduct this work, a literature search was carried out and a review was written based on guidelines, case reports, expert opinions and scientific publications. Toxidromes are a useful tool for classification of clinical characteristics when the causative agent is initially unknown. Especially in critical care medicine, identifying and quantifying of the causative toxin by enzyme immunoassays, chromatography and mass spectrometry should be attempted. Intensive care treatment of patients with acute overdoses includes not only monitoring and support of vital functions but also methods for primary and secondary elimination of toxins. The indication for the use of extracorporeal procedures should be carefully evaluated and the method should be chosen based on protein binding and molecular size. Lipid emulsion therapy, high-dose insulin euglycaemia therapy and hyperbaric oxygenation are also increasingly used.
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Value of glycolic acid analysis in ethylene glycol poisoning: A clinical case report and systematic review of the literature. Forensic Sci Int 2018; 290:e9-e14. [DOI: 10.1016/j.forsciint.2018.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 11/22/2022]
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12
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Gaddam M, Velagapudi RK, Abu Sitta E, Kanzy A. Two gaps too many, three clues too few? Do elevated osmolal and anion gaps with crystalluria always mean ethylene glycol poisoning? BMJ Case Rep 2017; 2017:bcr-2017-221739. [PMID: 29038192 DOI: 10.1136/bcr-2017-221739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 60-year-old African-American man with a medical history significant for heavy alcohol abuse, hypertension, delirium tremens, nephrolithiasis and seizure disorder was brought to the hospital with altered mental status. He was found to have high anion gap metabolic acidosis with significantly elevated lactate along with an elevated osmolal gap and calcium oxalate crystals in his urine. With this combination of findings, ethylene glycol poisoning was high in the differential. This case report describes why ethylene glycol poisoning was not the diagnosis in this patient despite the presence of these three classic laboratory findings, therefore emphasising the fact that these findings should not be taken at face value because they can be seen collectively in a patient yet each have a different cause.
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Affiliation(s)
- Maneesh Gaddam
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | | | - Emad Abu Sitta
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA.,Michigan State University
| | - Abed Kanzy
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
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Fowles J, Banton M, Klapacz J, Shen H. A toxicological review of the ethylene glycol series: Commonalities and differences in toxicity and modes of action. Toxicol Lett 2017; 278:66-83. [PMID: 28689762 DOI: 10.1016/j.toxlet.2017.06.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 05/23/2017] [Accepted: 06/21/2017] [Indexed: 11/27/2022]
Abstract
This review summarizes the hazards, exposure and risk that are associated with ethylene glycols (EGs) in their intended applications. Ethylene glycol (EG; CAS RN 107-21-1) and its related oligomers include mono-, di-, tri-, tetra-, and penta-EG. All of the EGs are quickly and extensively absorbed following ingestion and inhalation, but not by the dermal route. Metabolism involves oxidation to the mono- and dicarboxylic acids. Elimination is primarily through the urine as the parent compound or the monoacid, and, in the case of EG, also as exhaled carbon dioxide. All EGs exert acute toxicity in a similar manner, characterized by CNS depression and metabolic acidosis in humans and rodents; the larger molecules being proportionally less acutely toxic on a strict mg/kg basis. Species differences exist in the metabolism and distribution of toxic metabolites, particularly with the formation of glycolic acids and oxalates (OX) from EG and diethylene glycol (DEG); OX are not formed to a significant degree in higher ethylene glycols. Among rodents, rats are more sensitive than mice, and males more sensitive than females to the acute and repeated-dose toxicity of EG. The metabolic formation of glycolic acid (GA), diglycolic acid (DGA), and OX are associated with nephrotoxicity in humans and rodents following single and repeated exposures. However, physiological and metabolic differences in the rate of formation of GA, DGA and OX and their distribution result in EG and DEG causing embryotoxicity in rats, but not rabbits. This rodent-specific sensitivity indicates that EG and its higher oligomers are not anticipated to be embryotoxic in humans at environmentally relevant doses. None of the compounds present developmental toxicity concerns at doses that do not also cause significant maternal toxicity, nor do any of the EGs cause adverse effects on fertility. The EGs are neither genotoxic nor carcinogenic. A read-across matrix is presented, which considers the common and distinct toxicological properties of each compound. It is concluded that EGs pose no risk to human health as a result of their intended use patterns.
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Affiliation(s)
| | | | | | - Hua Shen
- Shell Oil Company, Houston, TX, USA
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Ethylene Glycol Poisoning: An Unusual Cause of Altered Mental Status and the Lessons Learned from Management of the Disease in the Acute Setting. Case Rep Crit Care 2016; 2016:9157393. [PMID: 27847651 PMCID: PMC5099479 DOI: 10.1155/2016/9157393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/24/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
Abstract
Ethylene glycol is found in many household products and is a common toxic ingestion. Acute ingestions present with altered sensorium and an osmolal gap. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. Early intervention is key; however, diagnosis is often delayed, especially in elderly patients presenting with altered mental status. There are several laboratory tests which can be exploited for the diagnosis, quantification of ingestion, and monitoring of treatment, including the lactate and osmolal gaps. As methods of direct measurement of ethylene glycol are often not readily available, it is important to have a high degree of suspicion based on these indirect laboratory findings. Mainstay of treatment is bicarbonate, fomepizole or ethanol, and, often, hemodialysis. A validated equation can be used to estimate necessary duration of hemodialysis, and even if direct measurements of ethylene glycol are not available, monitoring for the closure of the anion, lactate, and osmolal gaps can guide treatment. We present the case of an elderly male with altered mental status, acute kidney injury, elevated anion gap metabolic acidosis, and profound lactate and osmolal gaps.
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Abstract
Metabolic acidosis could emerge from diseases disrupting acid-base equilibrium or from drugs that induce similar derangements. Occurrences are usually accompanied by comorbid conditions of drug-induced metabolic acidosis, and clinical outcomes may range from mild to fatal. It is imperative that clinicians not only are fully aware of the list of drugs that may lead to metabolic acidosis but also understand the underlying pathogenic mechanisms. In this review, we categorized drug-induced metabolic acidosis in terms of pathophysiological mechanisms, as well as individual drugs’ characteristics.
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Affiliation(s)
- Amy Quynh Trang Pham
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Baylor Family Medicine Residency at Garland, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Li Hao Richie Xu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Department of Physiology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
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Abstract
CONTEXT Methanol, ethylene glycol, diethylene glycol, and propylene glycol intoxications are associated with cellular dysfunction and an increased risk of death. Adverse effects can develop quickly; thus, there is a need for methods for rapidly detecting their presence. OBJECTIVE To examine the value and limitations of present methods to diagnose patients with possible toxic alcohol exposure. METHODS I searched MEDLINE for articles published between 1969 and 2014 using the terms: toxic alcohols, serum osmolality, serum osmol gap, serum anion gap, metabolic acidosis, methanol, ethylene glycol, diethylene glycol, propylene glycol, and fomepizole. Each article was reviewed for additional references. RESULTS The diagnosis of toxic alcohol exposure is often made on the basis of this history and physical findings along with an increase in the serum osmol and anion gaps. However, an increase in the osmol and/or anion gaps is not always present. Definitive detection in blood requires gas or liquid chromatography, laborious and expensive procedures which are not always available. Newer methods including a qualitative colorimetric test for detection of all alcohols or enzymatic tests for a specific alcohol might allow for more rapid diagnosis. CONCLUSIONS Exposure to toxic alcohols is associated with cellular dysfunction and increased risk of death. Treatment, if initiated early, can markedly improve outcome, but present methods of diagnosis including changes in serum osmol and anion gap, and use of gas or liquid chromatography have important limitations. Development of more rapid and effective tests for detection of these intoxications is essential for optimal care of patients.
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Affiliation(s)
- Jeffrey A Kraut
- Medical and Research Services Veterans Administration Greater Los Angeles Healthcare System, UCLA Membrane Biology Laboratory, and Division of Nephrology, Veterans Administration Greater Los Angeles Healthcare System, and David Geffen School of Medicine , Los Angeles , California
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18
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Luciano RL, Perazella MA. Crystalline-induced kidney disease: a case for urine microscopy. Clin Kidney J 2014; 8:131-6. [PMID: 25815167 PMCID: PMC4370296 DOI: 10.1093/ckj/sfu105] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 09/18/2014] [Indexed: 12/31/2022] Open
Affiliation(s)
- Randy L Luciano
- Section of Nephrology , Yale University School of Medicine , New Haven, CT 06520 , USA
| | - Mark A Perazella
- Section of Nephrology , Yale University School of Medicine , New Haven, CT 06520 , USA
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19
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Zakhari R. Ethylene Glycol Poisoning: Resolution of Cranial Nerve Deficit. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Oxalate arthropathy is a rare cause of arthritis characterized by deposition of calcium oxalate crystals within synovial fluid. This condition typically occurs in patients with underlying primary or secondary hyperoxaluria. Primary hyperoxaluria constitutes a group of genetic disorders resulting in endogenous overproduction of oxalate, whereas secondary hyperoxaluria results from gastrointestinal disorders associated with fat malabsorption and increased absorption of dietary oxalate. In both conditions, oxalate crystals can deposit in the kidney leading to renal failure. Since oxalate is primarily renally eliminated, it accumulates throughout the body in renal failure, a state termed oxalosis. Affected organs can include bones, joints, heart, eyes, and skin. Since patients can present with renal failure and oxalosis before the underlying diagnosis of hyperoxaluria has been made, it is important to consider hyperoxaluria in patients who present with unexplained soft tissue crystal deposition. The best treatment of oxalosis is prevention. If patients present with advanced disease, treatment of oxalate arthritis consists of symptom management and control of the underlying disease process.
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Affiliation(s)
- Elizabeth C Lorenz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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McQuade DJ, Dargan PI, Wood DM. Challenges in the diagnosis of ethylene glycol poisoning. Ann Clin Biochem 2013; 51:167-78. [DOI: 10.1177/0004563213506697] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ethylene glycol poisoning, while uncommon, is clinically significant due to the associated risk of severe morbidity or lethality and it continues to occur in many countries around the world. The clinical presentation of ethylene glycol toxicity, while classically described in three phases, varies widely and when combined with the range of differential diagnoses that must be considered makes diagnosis challenging. Early and accurate detection is important in these patients, however, as there is a need to start antidotal treatment early to prevent serious harm. In this article, we will review the literature and provide guidance regarding the diagnosis of ethylene glycol poisoning. While gas chromatography is the gold standard, the usefulness of this test is hampered by delays in access due to availability. Consequently, there are several surrogate markers that can give an indication of ethylene glycol exposure but these must be interpreted with caution and within the clinical context. An in-depth review of these tests, particularly the detection of a raised osmolar gap or an raised anion gap acidosis, will form the main focus of this article.
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Affiliation(s)
- David J McQuade
- Emergency Department, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- King’s College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- King’s College London, London, UK
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22
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Murphy CM, Vitto MJ, Dulaney AR. Detectable serum ethylene glycol levels after subcutaneous injection of antifreeze. Clin Toxicol (Phila) 2013; 51:908-9. [PMID: 24032467 DOI: 10.3109/15563650.2013.834534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Christine M Murphy
- Department of Emergency Medicine, Carolinas Medical Center , Charlotte, NC , USA
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Monet C, Richard E, Missonnier S, Rebouissoux L, Llanas B, Harambat J. [Secondary hyperoxaluria and nephrocalcinosis due to ethylene glycol poisoning]. Arch Pediatr 2013; 20:863-6. [PMID: 23827374 DOI: 10.1016/j.arcped.2013.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 05/10/2013] [Accepted: 05/28/2013] [Indexed: 11/30/2022]
Abstract
We report the case of a 3-year-old boy admitted to the pediatric emergency department for ethylene glycol poisoning. During hospitalization, he presented dysuria associated with crystalluria. Blood tests showed metabolic acidosis with an elevated anion gap. A renal ultrasound performed a few weeks later revealed bilateral medullary hyperechogenicity. Urine microscopic analysis showed the presence of weddellite crystals. Secondary nephrocalcinosis due to ethylene glycol intoxication was diagnosed. Hyperhydration and crystallization inhibition by magnesium citrate were initiated. Despite this treatment, persistent weddellite crystals and nephrocalcinosis were seen more than 2years after the intoxication. Ethylene glycol is metabolized in the liver by successive oxidations leading to its final metabolite, oxalic acid. Therefore, metabolic acidosis with an elevated anion gap is usually found following ethylene glycol intoxication. Calcium oxalate crystal deposition may occur in several organs, including the kidneys. The precipitation of calcium oxalate in renal tubules can lead to nephrocalcinosis and acute kidney injury. The long-term renal prognosis is related to chronic tubulointerstitial injury caused by nephrocalcinosis. Treatment of ethylene glycol intoxication is based on specific inhibitors of alcohol dehydrogenase and hemodialysis in the most severe forms, and should be started promptly.
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Affiliation(s)
- C Monet
- Service de pédiatrie, hôpital Pellegrin-Enfants, CHU de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux, France
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Abstract
Accidental or intentional ingestion of substances containing methanol and ethylene glycol can result in death, and some survivors are left with blindness, renal dysfunction, and chronic brain injury. However, even in large ingestions, a favorable outcome is possible if the patient arrives at the hospital early enough and the poisoning is identified and appropriately treated in a timely manner. This review covers the common circumstances of exposure, the involved toxic mechanisms, and the clinical manifestations, laboratory findings, and treatment of methanol and ethylene glycol intoxication.
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Beatty L, Green R, Magee K, Zed P. A systematic review of ethanol and fomepizole use in toxic alcohol ingestions. Emerg Med Int 2013; 2013:638057. [PMID: 23431453 PMCID: PMC3574646 DOI: 10.1155/2013/638057] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/25/2012] [Indexed: 11/26/2022] Open
Abstract
Objectives. The optimal antidote for the treatment of ethylene glycol or methanol intoxication is not known. The objective of this systematic review is to describe all available data on the use of ethanol and fomepizole for methanol and ethylene glycol intoxication. Data Source. A systematic search of MEDLINE and EMBASE was conducted. Study Selection. Published studies involving the use of ethanol or fomepizole, or both, in adults who presented within 72 hours of toxic alcohol ingestion were included. Our search yielded a total of 145 studies for our analysis. There were no randomized controlled trials, and no head-to-head trials. Data Extraction. Variables were evaluated for all publications by one independent author using a standardized data collection form. Data Synthesis. 897 patients with toxic alcohol ingestion were identified. 720 (80.3%) were treated with ethanol (505 Me, 215 EG), 146 (16.3%) with fomepizole (81 Me, 65 EG), and 33 (3.7%) with both antidotes (18 Me, 15 EG). Mortality in patients treated with ethanol was 21.8% for Me and 18.1% for EG. In those administered fomepizole, mortality was 17.1% for Me and 4.1% for EG. Adverse events were uncommon. Conclusion. The data supporting the use of one antidote is inconclusive. Further investigation is warranted.
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Affiliation(s)
- Lorri Beatty
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Robert Green
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
- Division of Critical Care Medicine, Department of Anesthesia, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Kirk Magee
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Peter Zed
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada V6T 1Z3
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Oral Reference Dose for ethylene glycol based on oxalate crystal-induced renal tubule degeneration as the critical effect. Regul Toxicol Pharmacol 2012; 65:229-41. [PMID: 23266425 DOI: 10.1016/j.yrtph.2012.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/11/2012] [Accepted: 12/13/2012] [Indexed: 11/20/2022]
Abstract
Several risk assessments have been conducted for ethylene glycol (EG). These assessments identified the kidney as the primary target organ for chronic effects. None of these assessments have incorporated the robust database of species-specific toxicokinetic and toxicodynamic studies with EG and its metabolites in defining uncertainty factors used in reference value derivation. Pertinent in vitro and in vivo studies related to one of these metabolites, calcium oxalate, and its role in crystal-induced nephropathy are summarized, and the weight of evidence to establish the mode of action for renal toxicity is reviewed. Previous risk assessments were based on chronic rat studies using a strain of rat that was later determined to be less sensitive to the toxic effects of EG. A recently published 12-month rat study using the more sensitive strain (Wistar) was selected to determine the point of departure for a new risk assessment. This approach incorporated toxicokinetic and toxicodynamic data and used Benchmark Dose methods to calculate a Human Equivalent Dose. Uncertainty factors were chosen, depending on the quality of the studies available, the extent of the database, and scientific judgment. The Reference Dose for long-term repeat oral exposure to EG was determined to be 15 mg/kg bw/d.
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Holčapek M, Virelizier H, Chamot-Rooke J, Jandera P, Moulin C. Trace determination of glycols by HPLC with UV and electrospray ionization mass spectrometric detections. Anal Chem 2012; 71:2288-93. [PMID: 21662779 DOI: 10.1021/ac981087y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A high-performance liquid chromatography/mass spectrometry (HPLC/MS) method is developed for trace determination of glycols (ethylene glycol, 1,2- and 1,3-propylene glycols, and 2,3-butylene glycol) in water after derivatization with benzoyl chloride. Benzoyl esters of glycols are separated by microcolumn reversed-phase HPLC. Sensitivity and linearity of UV detection at 237 nm is compared with electrospray ionization mass spectrometric (ESI-MS) detection using selected ion monitoring. Limits of detection (LOD) and quantitation (LOQ) for UV detection are 1 and 2 mg/L, respectively. For ESI-MS detection, LOD and LOQ are in the ranges 10-25 and 20-50 μg/L, respectively. LOD obtained by ESI-MS for the determination of glycols is improved by 2-3 orders of magnitude in comparison to previously published methods. The effect of the structure of isomeric glycols on their electrospray mass spectra is discussed. The method has been applied for the determination of glycols in aqueous matrixes containing high concentrations of salts occurring in nuclear waste disposal treatment.
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Affiliation(s)
- M Holčapek
- Faculty of Chemical Technology, Department of Analytical Chemistry, University of Pardubice, nám. Čs.legií 565, 53210 Pardubice, Czech Republic, and CEA Saclay, DPE/SPCP/LASO, 91191 Gif sur Yvette Cedex, France
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Abstract
CONTEXT The kidney is a favored site for crystal deposition because of the high concentration of ions and molecules reached at the level of the renal tubules in the course of filtration. This review focuses on crystalline nephropathies in 4 broad categories: (1) dysproteinemia- associated, (2) drug-induced, (3) calcium-containing, and (4) metabolic or genetic. OBJECTIVE To provide a framework for accurate identification of the diverse types of crystals encountered in the kidney in order to formulate an appropriate differential diagnosis and guide additional testing and treatment. DATA SOURCES Review of pertinent published literature along with practical experience gained in a high-volume renal pathology laboratory. CONCLUSIONS Accurate identification of crystals encountered in the kidney is essential in detecting conditions ranging from hematologic malignancy to drug toxicity to metabolic disorders. Detailed clinical-pathologic correlation is needed to accurately diagnose the underlying cause of most crystalline nephropathies.
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Affiliation(s)
- Leal C Herlitz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY 10032, USA.
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McClain J, Uemura T, Sathishkumar S, Kadry Z. Liver donation after ethylene glycol overdose: when is it safe? Transpl Int 2012; 25:e55-7. [PMID: 22340516 DOI: 10.1111/j.1432-2277.2012.01436.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Neild GH, Torta E, Clari R, Boero R. Urine spoke well before the patient. Clin Kidney J 2012; 5:77. [PMID: 26069758 PMCID: PMC4400461 DOI: 10.1093/ndtplus/sfr169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 12/02/2022] Open
Affiliation(s)
- G H Neild
- Nephrology and Dialysis Unit, Ospedale Martini, Torino, Italy
| | - Elisa Torta
- Nephrology and Dialysis Unit, Ospedale Martini, Torino, Italy
| | - Roberta Clari
- Nephrology and Dialysis Unit, Ospedale Martini, Torino, Italy
| | - Roberto Boero
- Nephrology and Dialysis Unit, Ospedale Martini, Torino, Italy
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Coulter CV, Farquhar SE, McSherry CM, Isbister GK, Duffull SB. Methanol and ethylene glycol acute poisonings – predictors of mortality. Clin Toxicol (Phila) 2011; 49:900-6. [DOI: 10.3109/15563650.2011.630320] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Porter WH. Ethylene glycol poisoning: quintessential clinical toxicology; analytical conundrum. Clin Chim Acta 2011; 413:365-77. [PMID: 22085425 DOI: 10.1016/j.cca.2011.10.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/21/2011] [Accepted: 10/25/2011] [Indexed: 12/20/2022]
Abstract
Ethylene glycol poisoning is a medical emergency that presents challenges both for clinicians and clinical laboratories. Untreated, it may cause morbidly or death, but effective therapy is available, if administered timely. However, the diagnosis of ethylene glycol poisoning is not always straightforward. Thus, measurement of serum ethylene glycol, and ideally glycolic acid, its major toxic metabolite in serum, is definitive. Yet measurement of these structurally rather simple compounds is but simple. This review encompasses an assessment of analytical methods for the analytes relevant for the diagnosis and prognosis of ethylene glycol poisoning and of the role of the ethylene glycol metabolites, glycolic and oxalic acids, in its toxicity.
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Affiliation(s)
- William H Porter
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY, United States.
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Hovda KE, Julsrud J, Øvrebø S, Brørs O, Jacobsen D. Studies on ethylene glycol poisoning: one patient - 154 admissions. Clin Toxicol (Phila) 2011; 49:478-84. [PMID: 21824058 DOI: 10.3109/15563650.2011.590140] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Fomepizole is the antidote of choice in toxic alcohol poisonings. Potential side effects from frequent use of fomepizole were studied in a patient admitted 154 times with ethylene glycol (EG) poisoning. The intra-individual correlation between the serum-ethylene glycol (serum-EG) and the osmolal gap (OG) EG-kinetics, and other laboratory parameters were also studied. METHODS Combined pro- and retrospective collection of material from three different hospitals, and results from autopsy. RESULTS A 26-year-old female with a dissociative disorder was admitted with EG poisoning a total of 154 times. Her admission data revealed a median pH of 7.31 (range 6.87-7.49), pCO(2): 4.2 kPa (1.2-6.7) (32 mmHg [9-50]), HCO-3: 15 mmol/L (4-26) (15 mEq/L [4-26]), base deficit (BD): 10 mmol/L (- 4 to 27) (10 mEq/L [-4 to 27]), serum-creatinine 65 μmol/L (40-133) (0.74 mg/dL [0.45-1.51]), OG 81 mOsm/kgH(2)O (25-132), and serum-EG 44 mmol/L (4-112) (250 mg/dL [25-700]). She was treated with fomepizole 99 times, ethanol 60 times (with a combination of both six times), and dialysis 73 times. The correlation between serum-EG and OG was good (r(2) = 0.76). She was finally found dead outside hospital with an EG blood concentration of 81 mmol/L (506 mg/dL). An autopsy revealed calcium oxalate crystals in the kidneys, slight liver steatosis, and slight edema of the lungs. DISCUSSION The frequent use of fomepizole in this young patient was not associated with any detectable side effects; neither on clinical examination and lab screening, nor on the later autopsy. Regarding the sequelae from the repetitive EG-poisoning episodes, her kidney function seemed to normalize after each overdose. She was treated with buffer and antidote without hemodialysis 81 times without complications, supporting the safety of this approach in selected cases.
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Affiliation(s)
- Knut Erik Hovda
- The Norwegian NBC Center, Department of Acute Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway.
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Jialal I, Devaraj S. Laboratory diagnosis of ethylene glycol poisoning: the cup is half full? Am J Clin Pathol 2011; 136:165-6. [PMID: 21757590 DOI: 10.1309/ajcptzo0hrpkvpwm] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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35
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Juenke JM, Hardy L, McMillin GA, Horowitz GL. Rapid and specific quantification of ethylene glycol levels: adaptation of a commercial enzymatic assay to automated chemistry analyzers. Am J Clin Pathol 2011; 136:318-24. [PMID: 21757606 DOI: 10.1309/ajcpob9ypqiykglj] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Ethylene glycol ingestion, accidental or intentional, can be a life-threatening emergency. Assays are not available from most clinical laboratories, and, thus, results often require many hours or days to obtain. Enzymatic assays, adaptable to automated chemistry analyzers, have been evaluated, but they have been plagued by analytic problems. With an alternative method of data analysis applied to an existing enzymatic assay, a modified assay was developed and validated on 2 different automated chemistry systems. Compared with a previously validated method based on gas chromatography with flame ionization detection, the modified enzymatic assay showed excellent agreement on patient samples (y = 1.0227x -1.24; r(2) = 0.9725), with a large analytic measuring range (2.5-300 mg/dL [0.4-48.4 mmol/L]). Interferences from propylene glycol, various butanediols, and other related compounds were almost entirely eliminated; when present, they generated error flags rather than falsely elevated ethylene glycol results. This modified assay should make it possible for more clinical laboratories to offer ethylene glycol measurements.
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Oh MS. Uncoventional views on certain aspects of toxin-induced metabolic acidosis. Electrolyte Blood Press 2010; 8:32-7. [PMID: 21468195 PMCID: PMC3041497 DOI: 10.5049/ebp.2010.8.1.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 05/11/2010] [Indexed: 11/05/2022] Open
Abstract
This discussion will highlight the following 9 specific points that related to metabolic acidosis caused by various toxins. The current recommendation suggests that alcohol dehydrogenase inhibitor fomepizole is preferred to ethanol in treatment of methanol and ethylene glycol poisoning, but analysis of the enzyme kinetics indicates that ethanol is a better alternative. In the presence of a modest increase in serum osmolal gap (<30 mOsm/L), the starting dose of ethanol should be far less than the usual recommended dose. One can take advantage of the high vapor pressure of methanol in the treatment of methanol poisoning when hemodialysis is not readily available. Profuse sweating with increased water ingestion can be highly effective in reducing methanol levels. Impaired production of ammonia by the proximal tubule of the kidney plays a major role in the development of metabolic acidosis in pyroglutamic acidosis. Glycine, not oxalate, is the main final end product of ethylene glycol metabolism. Metabolism of ethylene glycol to oxalate, albeit important clinically, represents less than 1% of ethylene glycol disposal. Urine osmolal gap would be useful in the diagnosis of ethylene glycol poisoning, but not in methanol poisoning. Hemodialysis is important in the treatment of methanol poisoning and ethylene glycol poisoning with renal impairment, with or without fomepizole or ethanol treatment. Severe leucocytosis is a highly sensitive indicator of ethylene glycol poisoning. Uncoupling of oxidative phosphorylation by salicylate can explain most of the manifestations of salicylate poisoning.
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Affiliation(s)
- Man S Oh
- Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
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Abstract
Metabolic acidosis may occasionally develop in the course of treatment with drugs used in everyday clinical practice, as well as with the exposure to certain chemicals. Drug-induced metabolic acidosis, although usually mild, may well be life-threatening, as in cases of lactic acidosis complicating antiretroviral therapy or treatment with biguanides. Therefore, a detailed medical history, with special attention to the recent use of culprit medications, is essential in patients with acid-base derangements. Effective clinical management can be handled through awareness of the adverse effect of certain pharmaceutical compounds on the acid-base status. In this review, we evaluate relevant literature with regard to metabolic acidosis associated with specific drug treatment, and discuss the clinical setting and underlying pathophysiological mechanisms. These mechanisms involve renal inability to excrete the dietary H+ load (including types I and IV renal tubular acidoses), metabolic acidosis owing to increased H+ load (including lactic acidosis, ketoacidosis, ingestion of various substances, administration of hyperalimentation solutions and massive rhabdomyolysis) and metabolic acidosis due to HCO3- loss (including gastrointestinal loss and type II renal tubular acidosis). Determinations of arterial blood gases, the serum anion gap and, in some circumstances, the serum osmolar gap are helpful in delineating the pathogenesis of the acid-base disorder. In all cases of drug-related metabolic acidosis, discontinuation of the culprit medications and avoidance of readministration is advised.
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Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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McMartin K. Are calcium oxalate crystals involved in the mechanism of acute renal failure in ethylene glycol poisoning? Clin Toxicol (Phila) 2009; 47:859-69. [PMID: 19852621 DOI: 10.3109/15563650903344793] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Ethylene glycol (EG) poisoning often results in acute renal failure, particularly if treatment with fomepizole or ethanol is delayed because of late presentation or diagnosis. The mechanism has not been established but is thought to result from the production of a toxic metabolite. METHODS A literature review utilizing PubMed identified papers dealing with renal toxicity and EG or oxalate. The list of papers was culled to those relevant to the mechanism and treatment of the renal toxicity associated with either compound. ROLE OF METABOLITES: Although the "aldehyde" metabolites of EG, glycolaldehyde, and glyoxalate, have been suggested as the metabolites responsible, recent studies have shown definitively that the accumulation of calcium oxalate monohydrate (COM) crystals in kidney tissue produces renal tubular necrosis that leads to kidney failure. In vivo studies in EG-dosed rats have correlated the severity of renal damage with the total accumulation of COM crystals in kidney tissue. Studies in cultured kidney cells, including human proximal tubule (HPT) cells, have demonstrated that only COM crystals, not the oxalate ion, glycolaldehyde, or glyoxylate, produce a necrotic cell death at toxicologically relevant concentrations. COM CRYSTAL ACCUMULATION: In EG poisoning, COM crystals accumulate to high concentrations in the kidney through a process involving adherence to tubular cell membranes, followed by internalization of the crystals. MECHANISM OF TOXICITY: COM crystals have been shown to alter membrane structure and function, to increase reactive oxygen species and to produce mitochondrial dysfunction. These processes are likely to be involved in the mechanism of cell death. CONCLUSIONS Accumulation of COM crystals in the kidney is responsible for producing the renal toxicity associated with EG poisoning. The development of a pharmacological approach to reduce COM crystal adherence to tubular cells and its cellular interactions would be valuable as this would decrease the renal toxicity not only in late treated cases of EG poisoning, but also in other hyperoxaluric diseases such as primary hyperoxaluria and kidney stone formation.
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Affiliation(s)
- Kenneth McMartin
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Ting SMS, Ching I, Nair H, Langman G, Suresh V, Temple RM. Early and late presentations of ethylene glycol poisoning. Am J Kidney Dis 2009; 53:1091-7. [PMID: 19272685 DOI: 10.1053/j.ajkd.2008.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 12/12/2008] [Indexed: 12/15/2022]
Affiliation(s)
- Stephen M S Ting
- Renal Department, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands, UK.
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Stapenhorst L, Hesse A, Hoppe B. Hyperoxaluria after ethylene glycol poisoning. Pediatr Nephrol 2008; 23:2277-9. [PMID: 18696123 DOI: 10.1007/s00467-008-0917-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 04/13/2008] [Accepted: 05/19/2008] [Indexed: 12/12/2022]
Abstract
Treatment of otherwise lethal ethylene glycol poisoning depends on rapid diagnosis, aggressive supportive care, appropriate use of alcohol dehydrogenase inhibitors and, in selected patients, hemodialysis. Next to that, specific measures to prevent renal or systemic calcium-oxalate deposition are important. We report the case of a 12-year-old girl who ingested more than five times the lethal dosis of ethylene glycol in a suicide attempt. At admission her serum ethylene glycol concentration was 88 mg/dl. Under treatment by ethanol infusions to block the alcohol dehydrogenase and by hemodialysis to eliminate ethylene glycol and its toxic metabolites, this level decreased to below 15 mg/dl within 36 h. The plasma oxalate level, however, rose to a maximum of 89 micromol/l (normal <6.3 +/- 1.1) on day 3 and only normalized on day 7 after ingestion. In addition, urinary oxalate excretion was elevated (maximum 1.16 mmol/1.73 m(2)/24 h). Both lead to calcium-oxalate oversaturation and hence to the risk of local (renal) or systemic crystal deposition. Therefore, alkaline citrate was given as a preventive measure to increase urinary oxalate solubility, but nephrocalcinosis still developed. Metabolic acidosis, hypocalcaemia, and neurological symptoms had not occurred. Four weeks after discharge, both plasma and urinary oxalate levels were normal.
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Affiliation(s)
- Ludwig Stapenhorst
- Department of Pediatrics, University Children's Hospital, 50924, Cologne, Germany.
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Corley RA, Meek ME, Carney EW. Mode of Action: Oxalate Crystal-Induced Renal Tubule Degeneration and Glycolic Acid-Induced Dysmorphogenesis—Renal and Developmental Effects of Ethylene Glycol. Crit Rev Toxicol 2008; 35:691-702. [PMID: 16417036 DOI: 10.1080/10408440591007322] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Ethylene glycol can cause both renal and developmental toxicity, with metabolism playing a key role in the mode of action (MOA) for each form of toxicity. Renal toxicity is ascribed to the terminal metabolite oxalic acid, which precipitates in the kidney in the form of calcium oxalate crystals and is believed to cause physical damage to the renal tubules. The human relevance of the renal toxicity of ethylene glycol is indicated by the similarity between animals and humans of metabolic pathways, the observation of renal oxalate crystals in toxicity studies in experimental animals and human poisonings, and cases of human kidney and bladder stones related to dietary oxalates and oxalate precursors. High-dose gavage exposures to ethylene glycol also cause axial skeletal defects in rodents (but not rabbits), with the intermediary metabolite, glycolic acid, identified as the causative agent. However, the mechanism by which glycolic acid perturbs development has not been investigated sufficiently to develop a plausible hypothesis of mode of action, nor have any cases of ethylene glycol-induced developmental effects been reported in humans. Given this, and the variations in sensitivity between animal species in response, the relevance to humans of ethylene glycol-induced developmental toxicity in animals is unknown at this time.
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Affiliation(s)
- Richard A Corley
- Pacific Northwest National Laboratory, Richland, Washington 99352, USA.
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Abstract
OBJECTIVES Many hospitals must send out ethylene glycol (EG) samples to a reference laboratory, and delays in diagnosis and treatment may occur. A qualitative colorimetric test (ethylene glycol test [EGT] kit), already in use by veterinarians, gives results in 30 minutes with little expertise or cost. The EGT reliably detects the presence of EG in spiked human serum samples. The objective of this study was to prospectively assess the sensitivity and specificity of the EGT kit in actual clinical samples submitted for EG testing by the criterion standard gas chromatography (GC). METHODS Blood samples from patients with suspected toxic alcohol poisoning submitted to a reference laboratory were tested by GC. An investigator blinded to the GC results tested the same sample with the EGT kit following the manufacturer's instructions and using the internal control. Three physicians also blinded to the GC results categorized the sample as positive for EG, negative, or inconclusive. Interrater reliability was assessed with a kappa statistic (kappa). Results of the EGT kit testing were then compared to those from GC testing. RESULTS Data are reported on 24 samples submitted. By GC, 15 samples were confirmed for EG (range 27-281 mg/dL), 5 were confirmed for methanol (ME; range 64-101 mg/dL), and 4 were negative for both alcohols. The EGT was unanimously positive in all confirmed EG samples and negative in all ME samples. In one of the negative samples, an ambiguous result occurred and was counted as a false-positive. Interobserver agreement with the EGT was high (kappa = 0.909; 95% confidence interval [CI] = 0.735 to 1.0). Sensitivity and specificity were 100% (95% CI = 70% to 100%) and 88.8% (95% CI = 52% to 100%), respectively. CONCLUSIONS The EGT appears to be a reliable qualitative test in cases of suspected human EG poisoning.
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Affiliation(s)
- Heather Long
- Department of Emergency Medicine, St. Peter's Hospital, Albany, NY, USA.
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Upadhyay S, Carstens J, Klein D, Faller TH, Halbach S, Kirchinger W, Kessler W, Csanády GA, Filser JG. Inhalation and epidermal exposure of volunteers to ethylene glycol: kinetics of absorption, urinary excretion, and metabolism to glycolate and oxalate. Toxicol Lett 2008; 178:131-41. [PMID: 18430528 DOI: 10.1016/j.toxlet.2008.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 02/22/2008] [Accepted: 02/22/2008] [Indexed: 11/17/2022]
Abstract
Ethylene glycol (EG) is a widely used liquid. Limited data are published regarding inhaled EG and no data regarding transdermal EG uptake in humans. In order to gain information on the quantitative fate of EG, four male volunteers inhaled between 1340 and 1610 micromol vaporous 13C-labeled EG (13C2-EG) for 4h. Separately, three of these subjects were epidermally exposed for up to 6h to liquid 13C2-EG (skin area 66 cm2). Plasma concentrations and urinary amounts of 13C2-EG were determined by gas chromatography with mass selective detection. Additionally, plasma was assayed for 13C-labeled glycolic acid 13C2-GA) and urine for 13C2-GA and 13C-labeled oxalic acid (13C2-OA). Both EG metabolites were nephrotoxic in animals and humans and embryotoxic in rodents. 13C-labels enabled to differentiate from also determined endogenous EG, glycolic acid (GA), and oxalic acid (OA). Of 13C2-EG inhaled, 5.5+/-3.0%, 0.77+/-0.15%, and 0.10+/-0.12% were detected in urine as 13C2-EG, 13C2-GA, and 13C2-OA, respectively. The skin permeability constant of liquid EG was 2.7 x 10(-5)+/-0.5 x 10(-5)cm/h. Of the dose taken up transdermally, 8.1+/-3.2% and up to 0.4% were excreted in urine as 13C2-EG and 13C2-GA, respectively. It is calculated that equally long-lasting exposure to 10 ppm vaporous EG or wetting of both hands by liquid EG leads to about the same body burden by EG and metabolites. The amounts of GA and OA excreted daily in urine as a result of exposure (8h/day) to 10 ppm EG are about 15% and 2%, respectively, of those excreted from naturally occurring endogenous GA and OA.
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Affiliation(s)
- Swapna Upadhyay
- Institute of Toxicology, Helmholtz Zentrum München, German Research Center for Environmental Health, D-85764 Neuherberg, Germany
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Fang HC, Lee PT, Lu PJ, Chen CL, Chang TY, Hsu CY, Chung HM, Chou KJ. Mechanisms of star fruit-induced acute renal failure. Food Chem Toxicol 2008; 46:1744-52. [PMID: 18294746 DOI: 10.1016/j.fct.2008.01.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 01/08/2008] [Accepted: 01/09/2008] [Indexed: 12/12/2022]
Abstract
We have previously discovered that star fruit can induce oliguric acute renal failure. To investigate the mechanisms of star fruit-associated acute oxalate nephropathy, the nephrotoxic effect of star fruit was examined in both cellular experiments and animal models. We evaluated renal function, pathological changes in kidney tissues and apoptotic effects using terminal deoxynucleotidyl transferase nick-end labeling (TUNEL) assay in four groups of rats -- a control group (CG), fed with tap water (1); a star fruit group (SG), fed with star fruit juice naturally containing 0.2M oxalate (2); and oxalate groups (OxG), fed with 0.2M (3) or 0.4M (4) oxalate solution. The effects of both star fruit juice and oxalate on MDCK cells were also analyzed by flow cytometry. We found that the mean creatinine clearance was significantly lower in the SG, 0.2M OxG and 0.4M OxG. Dose-dependent apoptotic effects were evident from the TUNEL assay, and flow cytometry analysis of treated MDCK cells showed dose- and time-dependent effects. Our findings suggest that star fruit juice produces acute renal injury, not only through the obstructive effect of calcium oxalate crystals, but also by inducing apoptosis of renal epithelial cells, which may be caused by the levels of oxalate in the fruit.
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Affiliation(s)
- Hua-Chang Fang
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Briefly Noted. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1988.tb00759.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Guo C, Cenac TA, Li Y, McMartin KE. Calcium oxalate, and not other metabolites, is responsible for the renal toxicity of ethylene glycol. Toxicol Lett 2007; 173:8-16. [PMID: 17681674 DOI: 10.1016/j.toxlet.2007.06.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2007] [Revised: 06/05/2007] [Accepted: 06/05/2007] [Indexed: 11/26/2022]
Abstract
Ethylene glycol (EG) is nephrotoxic due to its metabolism. Many studies suggest that the toxicity is due to oxalate accumulation, but others have conversely suggested that toxicity results from effects of metabolites such as glycolaldehyde or glyoxylic acid on proximal tubule cells. In vivo studies have indicated that accumulation of calcium oxalate monohydrate (COM) corresponds closely with development of toxicity in renal tissue. The present studies were therefore designed to clarify the roles of various metabolites in the mechanism for EG toxicity in vitro by comparing the relative cytotoxicity of EG metabolites using three measures of cell death, ethidium homodimer uptake, lactate dehydrogenase (LDH) release and the conversion of the tetrazolium salt XTT to a colorimetric dye. Human proximal tubule cells in culture were incubated in physiologic buffers for 6h at 37 degrees C with COM (147-735microg/ml, an oxalate equivalence of 1-5mM), glycolate (5-25mM), glyoxylate (0.2-5mM) and glycolaldehyde (0.2-2mM). To assess the effects of acidity on the cytotoxicity, incubations were carried out at pH 6-7.4. The results show that COM dose-dependently increased LDH release and ethidium homodimer uptake, while the other metabolites did not. Conversely, COM had no effect on the XTT assay, while high concentrations of glycolaldehyde and glyoxylate decreased XTT activity, but the latter only at acidic pH. The correlation between the uptake of ethidium homodimer and the release of LDH suggest that COM is cytotoxic to human kidney cells in culture, while the XTT assay does not validly measure cytotoxicity in this system. These results indicate that COM, and not glyoxylate or glycolaldehyde, is the toxic metabolite responsible for the acute tubular necrosis and renal failure that is observed in EG-poisoned patients.
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Affiliation(s)
- Chungang Guo
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130-3932, United States
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Abstract
Numerous drugs and toxins may induce the development of a metabolic acidosis. The treating physician should be cognizant of the many compounds that can produce metabolic acidosis following an overdose or an accidental exposure, or with therapeutic use. Knowledge and comprehension of the substances associated with metabolic acidosis will facilitate the diagnosis and treatment of poisoned patients.
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Affiliation(s)
- Bryan S Judge
- DeVos Children's Hospital Regional Poison Center, Grand Rapids, MI 49503, USA.
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Correspondence to: “The cytotoxicity of oxalate, metabolite of ethylene glycol, is due to calcium oxalate monohydrate formation” [Toxicology 208(3) 2005, 347–355]. Toxicology 2006. [DOI: 10.1016/j.tox.2006.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Takayesu JK, Bazari H, Linshaw M. Case records of the Massachusetts General Hospital. Case 7-2006. A 47-year-old man with altered mental status and acute renal failure. N Engl J Med 2006; 354:1065-72. [PMID: 16525144 DOI: 10.1056/nejmcpc059043] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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