Emergency department hemodialysis in a case of severe ethylene glycol poisoning

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

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.

Time-dependent changes in kidney histopathology in ethylene glycol poisoning

Ethylene glycol (EG) may be acutely toxic following ingestion. In fatal cases, microscopic examination of urine and kidney specimens can establish a post-mortem diagnosis of EG poisoning. We describe the main renal histopathologic changes during different stages of EG poisoning, which might be helpful when dating the EG poisoning itself. A single-centre retrospective study conducted on all EG poisoning cases demonstrated that in an early stage of EG poisoning, fine dust-like crystals were deposited to the tubular cell basement membrane, followed by internalisation of calcium oxalate crystals into the epithelial cells. Later, the crystals formed larger aggregates within the epithelial cells. As the changes became advanced, pronounced tubular epithelial damage occurred, with detachment of epithelial cells from the basement membrane. In the final stage, coarse calcium oxalate crystals were recognised in the tubular lumen, with cellular debris from damaged epithelial cells. Our study shows that the time-dependent histological changes described follow the clinical stages of EG poisoning and may therefore provide a rough estimate of the time of EG ingestion before death.

A systematic review of ethanol and fomepizole use in toxic alcohol ingestions

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.

Ethylene glycol poisoning: quintessential clinical toxicology; analytical conundrum

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.

A fatal case involving extremely high levels of ethylene glycol without elevation of its metabolites or crystalluria

A unique case of an intentional overdose of ethylene glycol resulting in a fatality is described. The decedent had a very high concentration of ethylene glycol without elevated concentrations of its metabolites or crystalluria. The ethylene glycol concentrations in blood, urine, and vitreous fluid were 2340, 2261, and 1028 mg/dL, respectively. Osmolality of blood and vitreous fluid was also very high at 1426 and 534 mOsm/kg, respectively. No crystals were found in the urine. Furthermore, on the urine organic acids profile the ethylene glycol metabolites oxalic, glycolic, and glyoxylic acids were within the reference ranges. In addition to ethylene glycol, the decedent had an elevated level of mirtazapine, an antidepressant, and a low level of bupropion. It was estimated that the subject consumed 1034 g of ethylene glycol. To our knowledge, this is the first case of death from severe ethylene glycol poisoning in the absence of ethylene glycol metabolites or crystalluria.

[Severe ethylene glycol intoxication by skin absorption]

Ethylene glycol is present predominantly in antifreeze,and in industrial solvents. Accidental ingestion of ethylene glycol is relatively rare, but may be potentially lethal. It results in a depression of the central nervous system, a severe metabolic acidosis and an acute renal failure by tubular precipitation of calcium oxalate crystals. We report a case of ethylene glycol poisoning by through skin absorption.

OBSERVATION

A 38-year-old man, working in a cement factory, with a history of cutaneous psoriasis for 10 years, was admitted to our hospital due to acute nausea, vomiting and diffuse abdominal pain, followed by generalized convulsive status epilepticus and worsening of his mental status. Biologic analysis showed severe metabolic acidosis and acute renal failure which required hemodialysis. On renal biopsy, there were intratubular crystals of calcium oxalate. Cerebral magnetic resonance imaging showed posterior encephalitis. Evolution was marked by normalization of renal function at two weeks and improvement of the mental status. Retrospectively, the patient's history-taking revealed that he manipulated ethylene glycol without gloves.

CONCLUSION

Cutaneous contact with ethylene glycol may cause poisoning in presence of skin lesions. The triad neurologic involvement, renal failure due to oxalate crystals deposits and metabolic acidosis leads to the diagnosis of ethylene glycol intoxication. In the case of acute renal failure with oliguria, haemodialysis is the treatment of choice. It allows the removal of the toxic substance and its metabolites with correction of the metabolic acidosis. The precocity of the treatment may improve the prognosis.

Ethylene glycol ingestion treated only with fomepizole

INTRODUCTION

Ethylene glycol is a widely used chemical that is capable of causing significant injury if ingested. Treatment for ethylene glycol poisoning typically includes basic supportive care, alcohol dehydrogenase inhibition, and hemodialysis. Recent data have suggested that hemodialysis may not be necessary for cases of ethylene glycol poisoning that can be treated with fomepizole as blocking therapy before acidosis or renal dysfunction develops.

CASE REPORT

A 33-year-old man presented to the emergency department 1 hour after drinking approximately 1/2 gallon of ethylene glycol antifreeze and an unknown quantity of beer. On arrival he was mildly inebriated but otherwise displayed no other features of ethylene glycol poisoning. Fomepizole therapy was initiated and initial laboratory studies later revealed an osmol gap of 157 mOsm and an ethylene glycol concentration of 706 mg/dL. Nephrology and toxicology services were consulted. Over the next 3 days, fomepizole therapy was continued while the patient's acid-base status and renal function were closely monitored. No evidence of acid-base abnormalities or renal impairment was ever observed and the patient was discharged to psychiatric care on the fourth hospital day.

DISCUSSION

This report describes the case of a patient who presented soon after a massive ingestion of ethylene glycol with very high serum concentrations. He was successfully treated using fomepizole and basic supportive care. Our patient developed neither renal insufficiency nor metabolic acidosis. His concomitant ethanol consumption, early presentation, and treatment likely contributed to his favorable outcome. This case report underscores the effectiveness of supportive care and fomepizole in the treatment of ethylene glycol poisoning.

Hyperosmolality: another indication for hemodialysis following acute ethylene glycol poisoning

When given early, fomepizole has demonstrated an effective role in the treatment of ethylene glycol (EG) intoxication, often eliminating the need for hemodialysis (HD). Many indications for HD have been suggested for EG intoxication. We present a case of EG intoxication with the second highest reported EG concentration. Despite early treatment with fomepizole and without the development of acidosis or renal insufficiency, the patient required HD for hyperosmolality and subsequent electrolyte imbalances. Indications for HD following EG intoxication are discussed.

Determination of ethylene glycol tissue content after fatal oral poisoning and pathologic findings

A 23-year-old comatose man who had drunk an unknown amount of ethylene glycol was admitted to the hospital 5 hours after ingestion. The initial plasma ethylene glycol concentration was 116.2 mg/100 ml. A severe metabolic acidosis was present. Despite aggressive therapy with ethanol, hemodialysis, and intensive care support, the patient died 27 hours after poisoning. The plasma ethylene glycol concentration immediately before death was 35.9 mg/100 ml. Brain edema and acute renal tubular necrosis were evident at postmortem examination. Oxalate crystals were identified in both organs. Ethylene glycol content or concentration was determined in tissues and biologic fluids.

Treatment of the alcohol intoxications: ethylene glycol, methanol and isopropanol

Intoxications with ethylene glycol, methanol, and isopropanol are among the most common ingestions, in the treatment of which a nephrologist plays an important role. These three substances have the ideal characteristics for intervention by hemodialysis, and the three parent compounds and their metabolites are readily dialyzable. Two of the three substances, ethylene glycol and methanol, are metabolized to more toxic substances, so that an early treatment strategy that removes the parent compound or blocks its metabolism can prevent the development of many of the adverse events that are often seen in these ingestions. Fomepizole, an inhibitor of alcohol dehydrogenase, slows the metabolism of these substances and is now approved by the US Food and Drug Administration for use in ethylene glycol intoxication. The present review addresses recent advances in the diagnosis and treatment of intoxication with ethylene glycol, methanol and isopropanol.

American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Ad Hoc Committee

Fomepizole (4-methylpyrazole, 4-MP, Antizol) is a potent inhibitor of alcohol dehydrogenase that was approved recently by the US Food and Drug Administration (FDA) for the treatment of ethylene glycol poisoning. Although ethanol is the traditional antidote for ethylene glycol poisoning, it has not been studied prospectively. Furthermore, the FDA has not approved the use of ethanol for this purpose. Case reports and a prospective case series indicate that the intravenous (i.v.) administration of fomepizole every 12 hours prevents renal damage and metabolic abnormalities associated with the conversion of ethylene glycol to toxic metabolites. Currently, there are insufficient data to define the relative role of fomepizole and ethanol in the treatment of ethylene glycol poisoning. Fomepizole has clear advantages over ethanol in terms of validated efficacy, predictable pharmacokinetics, ease of administration, and lack of adverse effects, whereas ethanol has clear advantages over fomepizole in terms of long-term clinical experience and acquisition cost. The overall comparative cost of medical treatment using each antidote requires further study.