Zehirlenmelerde Ekstrakorporeal Tedaviler

Ekstrakorporeal tedaviler (EKT), endojen veya ekzojen toksinlerin vücuttan uzaklaştırılması ve/veya hayati organlardan birinin geçici bir süreliğine replasmanını içeren heterojen bir grup tedavi yöntemini içerir. Konvansiyonel tedavilere cevap vermeyen uygun intoksikasyon vakalarında EKT yöntemleri, mortalite ve morbiditenin önlenmesinde anahtar rol oynayabilir. Genel olarak molekül ağırlığı, endojen klirensi ve dağılım hacmi düşük olan ve proteine az bağlanan toksinler EKT uygulamaları ile uzaklaştırılmaya uygundur. Günümüzde en sık uygulanan EKT yöntemleri aralıklı hemodiyaliz, aralıklı hemofiltrasyon/hemodiafiltrasyon, sürekli renal replasman tedavileri, hemoperfüzyon, terapötik plazma değişimi, exchange transfüzyon, albümin diyalizi ve ekstrakorporeal membran oksijenizasyonudur. EKT yöntemleri, bazı komplikasyon risklerini de beraberinde getiren invaziv işlemlerdir. Bu nedenle, EKT’den olası fayda görebilecek tüm toksin maruziyetlerinde de mutlaka yarar ve risk oranı vaka bazlı değerlendirilerek uygulama kararı verilmelidir. Hasta için en uygun EKT yöntemi belirlenmesi sırasında ise hem maruzkalınantoksinin özellikleri hem de hastanın medikal öykü ve klinik durumu dikkate alınmalıdır. Yakın gelecekte EKT uygulamaları ile ilgili vaka takdiminin ötesinde geniş çapta verilerin literatüre sunulması, bu yöntemlerin optimal kullanım stratejilerini belirmeye yardımcı olacaktır.

Anahtar Kelimeler:

ekstrakorporeal tedavi, intoksikasyon, hemodiyaliz, toksikoloji

Extracorporeal Treatments in Poisoning

Extracorporeal treatments (ECT) include a heterogeneous group of methods for the removal of endogenous or exogenous toxins from the body and/or for the temporary replacement of one of the vital organs.ECT methods may play a key role in preventing mortality and morbidity in appropriate intoxication cases that do not respond to conventional treatments. In general, toxins with low molecular weight, low endogenous clearance, low volume of distribution and low protein binding are suitable for removal by ECT methods. Currently, the most common ECT methods are intermittent hemodialysis, intermittent hemofiltration/hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, albumin dialysis and extracorporeal membrane oxygenation.ECT methods are invasive procedures that bring some risks of complications. Therefore, in all toxin exposures that may benefit from ECT, the application decision should be made by evaluating the benefit and risk ratio on a case-by-case basis. In determining the most appropriate ECT method for the patient, both the characteristics of the toxin exposed and also the medical history and clinical status of the patient should be taken into consideration.In the near future, presenting a wide range of data about ECT applications beyond the case presentations to the literature will help to determine the optimal use strategies of these methods.

Keywords:

extracorporeal treatment, intoxication, toxicology, hemodialysis,

PDF

___

Mowry JB, Spyker DA, Cantilena LR Jr, Bailey JE, Ford M. 2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 30th Annual Report. Clin Toxicol. 2013; 51: 949-1229.
Ouellet G, Bouchard J, Ghannoum M, Decker BS. Available extracorporal treatments for poisoning: overview and limitations. Semin Dial. 2014; 27(4): 342-9.
Abel JJ, Roundtree LG, Turner BB. On the removal of diffusible substances from the circulating blood of living animals by dialysis. J Pharmacol. Exp Ther. 1914; 5: 275-316.
Patel N, Bayliss GP. Developments in extracorporal therapy fort he poisoned patient. Adv Drug Deliv Rev. 2015; 90: 3-11.
Ghannoum M, Hoffman RS, Gosselin S, Nolin TD, Lavergne V, Roberts DM. Use of extracorporal treatments in the management of poisonings. Kidney Int. 2018; 94(4): 682-8.
Ghannoum M, Roberts DM, Hoffman RS, Ouellet G, Roy L, Decker BS, et al. A stepwise approach for the management of poisoning with extracorporeal treatments. Semin Dial. 2014; 27: 362-70.
Martin-Reyes G, Toledo-Rojas R, Torres-de Rueda A, Sola-Moy- ano E, Blanca-Martos L, Fuentes-Sanchez L, et al. Haemodialysis using high cut-off dialysers for treating acute renal failure in multiple myeloma. Nefrologia. 2012; 32: 35-43.
Ibrahim RB, Liu C, Cronin SM, Murphy BC, Cha R, Swerdlow P, et al. Drug removal by plasmapheresis: an evidence-based review. Pharmacotherapy. 2007; 27: 1529-49.
Matzke GR. Status of hemodialysis of drugs in 2002. J Pharm Pract. 2002; 15: 405-18.
De Pont AC. Extracorporeal treatment of intoxications. Curr Opin Crit Care. 2007; 13: 668-73.
Krisper P, Stauber RE. Technology insight: artificial extracorporeal liver support-how does Prometheus compare with MARS? Nat Clin Pract Nephrol. 2007; 3: 267-76.
Kawasaki CI, Nishi R, Uekihara S, Hayano S, Kragh-Hansen U, Otagiri M. How tightly can a drug be bound to a protein and still be removable by charcoal hemoperfusion in overdose cases? Clin Toxicol. 2005; 43: 95-9.
Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal removal tech- niques for the poisoned patient: a review for the intensivist. J Inten- sive Care Med. 2010; 25: 139-148.
Pond SM. Extracorporeal techniques in the treatment of poisoned patients. Med J Aust. 1991; 154: 617-22.
Holubek WJ, Hoffman RS, Goldfarb DS, Nelson LS. Use of hemodialysis and hemoperfusion in poisoned patients. Kidney Int. 2008; 74: 1327-34.
Shannon MW. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication. Acad Emerg Med. 1997; 4: 674-8.
Tyagi PK, Winchester JF, Feinfeld DA. Extracorporeal removal of toxins. Kidney Int. 2008; 74: 1231-3.
Ward RA, Schmidt B, Hullin J, Hillebrand GF, Samtleben W. A comparison of on-line hemodiafiltration and high-flux hemodialysis: a prospective clinical study. J Am Soc Nephrol. 2000; 11: 2344-50.
Ahrenholz PG, Winkler RE, Michelsen A, Lang DA, Bowry SK. Dialysis membrane-dependent removal of middle molecules during hemodiafiltration: the beta2-microglobulin/albumin relationship. Clin Nephrol. 2004; 62: 21-8.
Yamashita AC. Mechanisms of solute and fluid removal in hemodiafiltration. Contrib Nephrol. 2007; 158: 50-6.
Bailey AR, Sathianathan VJ, Chiew AL, Paterson AD, Chan BS, Arora S. Comparison of intermittent haemodialysis, prolonged intermittent renal replacement therapy and continuous renal replacement haemofiltration for lithium toxicity: a case report. Crit Care Resusc. 2011; 13: 12-2.
Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, et al. Extracorporeal treatment for metformin poisoning: systematic review and recommendations from the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med. 2015; 43: 1716-30.
Decker BS, Goldfarb DS, Dargan PI, Friesen M, Gosselin S, Hoffman RS, et al. Extracorporeal treatment for lithium poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin J Am Soc Nephrol. 2015; 10: 875-87.
Roberts DM, Yates C, Megarbane B, Winchester JF, Maclaren R, Gosselin S, et al. Recommendations for the role of extracorporeal treatments in the management of acute methanol poisoning: a systematic review and consensus statement. Crit Care Med. 2015; 43(2): 461-72.
Ghannoum M, Bouchard J, Nolin TD, Ouellet G, Roberts DM. Hemoperfusion for the treatment of poisoning: technology, determinants of poison clearance, and application in clinical practice. Semin Dial. 2014; 27: 350-61.
Rahman MH, Haqqie SS, McGoldrick MD. Acute hemolysis with acute renal failure in a patient with valproic acid poisoning treated with charcoal hemoperfusion. Hemodial Int. 2006; 10: 256-9.
Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linen- berger ML, Marques MB, et al. Apheresis Applications Committee of the American Society for A. Guidelines on the use of therapeutic apheresis in clinical practice–evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher. 2010; 25: 83-177.
Schutt RC, Ronco C, Rosner MH. The role of therapeutic plasma exchange in poisonings and intoxications. Semin Dial. 2012; 25: 201-6.
Jander S, Bischoff J, Woodcock BG. Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations. Ther Apher. 2000; 4: 308-12.
Jha S, Waghdhare S, Reddi R, Bhattacharya P. Thyroid storm due to inappropriate administration of a compounded thyroid hormone preparation successfully treated with plasmapheresis. Thyroid. 2012; 22: 1283-6.
Chu G, Mantin R, Shen YM, Baskett G, Sussman H. Massive cisplatin overdose by accidental substitution for carboplatin. Toxicity and management. Cancer. 1993; 72: 3707-14.
Pierga JY, Beuzeboc P, Dorval T, Palangie T, Pouillart P. Favourable outcome after plasmapheresis for vincristine overdose. Lancet. 1992; 340:185.
Schonermarck U, Bosch T. Vascular access for apheresis in inten- sive care patients. Ther Apher Dial. 2003; 7: 215-20.
Leitner GC, Hiesmayr M, Hoecker P, Jilma B. Therapeutic approaches in the management of oral cyclosporine A intoxication. Transplantation. 2003; 75: 1764-5.
McCarthy H, Inward C, Marriage S, Astley P, Tizard EJ. Red cell exchange transfusion as a rescue therapy for tacrolimus toxicity in a paediatric renal transplant. Pediatr Nephrol. 2011; 26: 2245-8.
Mier RJ. Treatment of aniline poisoning with exchange transfusion. J Toxicol Clin Toxicol. 1988; 26(5-6): 357-64.
Southgate HJ, Masterson R. Lessons to be learned: a case study approach: prolonged methaemoglobinaemia due to inadvertent dap- sone poisoning; Treatment with methylene blue and exchange transfusion. J R Soc Promot Health. 1999; 119(1): 52-5.
Manikian A, Stone S, Hamilton R, Foltin G, Howland MA, Hoffman RS. Exchange transfusion in severe infant salicylism. Vet Hum Toxicol. 2002; 44: 224-7.
Osborn HH, Henry G, Wax P, Hoffman R, Howland MA. Theophylline toxicity in a premature neonate–elimination kinetics of exchange transfusion. J Toxicol Clin Toxicol. 1993; 31: 639-44.
Sancak R, Kucukoduk S, Tasdemir HA, Belet N. Exchange transfu- sion treatment in a newborn with phenobarbital intoxication. Pediatr Emerg Care. 1999; 15: 268-70.
Wittebole X, Hantson P. Use of the molecular adsorbent recirculating system (MARS?) for the management of acute poisoning with or without liver failure. Clin Toxicol. 2011; 49: 782-93.
Sen S, Ratnaraj N, Davies NA, Mookerjee RP, Cooper CE, Patsalos PN, et al. Treatment of phenytoin toxicity by the molecular adsorbents recirculating system (MARS). Epilepsia. 2003; 44: 265-7.
Korsheed S, Selby NM, Fluck RJ. Treatment of severe theophylline poisoning with the molecular adsorbent recirculating system (MARS). Nephrol Dial Transplant. 2007; 22: 969-70.
Dichtwald S, Dahan E, Adi N, Moses A, Sorkine P. Molecular adsorbent recycling system therapy in the treatment of acute valproic acid intoxication. Israel Med Assoc J. 2010; 12(5): 307-8.
Banner W. Risks of extracorporeal membrane oxygenation: is there a role for use in the management of the acutely poisoned patient? J Toxicol Clin Toxicol. 1996; 34: 365-71.
Babatasi G, Massetti M, Verrier V, Lehoux P, Le Page O, Bruno PG, et al. Severe intoxication with cardiotoxic drugs: value of emergency percutaneous cardiocirculatory assistance. Arch Mal Coeur Vaiss. 2001; 94: 1386-92.
Scalzo AJ, Weber TR, Jaeger RW, Connors RH, Thompson MW. Extracorporeal membrane oxygenation for hydrocarbon aspiration. Am J Dis Child. 1990; 144: 867-71.
Chyka PA. Benefits of extracorporeal membrane oxygenation for hydrocarbon pneumonitis. J Toxicol Clin Toxicol. 1996; 34: 357-63.