Hemodialysis for Intoxications

Indications for Hemodialysis

The American College of Emergency Physicians recommends hemodialysis for severe salicylate poisoning with altered mental status, acute respiratory distress syndrome, or failure of standard therapy, with a strong recommendation for levels >7.2 mmol/L (100 mg/dL) 1, 2
The American College of Emergency Physicians conditionally recommends hemodialysis for salicylate levels >6.5 mmol/L (90 mg/dL), with lower thresholds applying for patients with impaired kidney function 1, 2
The Critical Care society strongly recommends hemodialysis for ethylene glycol poisoning with glycolate concentration >12 mmol/L, anion gap >27 mmol/L, or severe clinical features such as coma, seizures, or acute kidney injury 3, 4
The Critical Care society conditionally recommends hemodialysis for ethylene glycol poisoning with glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L 3, 4

The American College of Emergency Physicians and Critical Care society prefer intermittent hemodialysis over other extracorporeal treatments for all intoxications 2, 4
The American College of Emergency Physicians recommends hemoperfusion as an alternative modality for salicylate poisoning, followed by continuous renal replacement therapy (CRRT) 2
The Critical Care society recommends CRRT as an alternative modality for ethylene glycol poisoning if intermittent hemodialysis is unavailable 4

The American College of Emergency Physicians advises against delaying hemodialysis for salicylate poisoning based on clinical improvement alone, as concentrations >7.2 mmol/L warrant treatment regardless of symptoms 1
The Critical Care society recommends adjusting antidote dosing (fomepizole or ethanol) during hemodialysis, as these are dialyzable, and increasing fomepizole dosing frequency to every 4 hours during hemodialysis 4
The Critical Care society advises against assuming adequate treatment based solely on improving pH, and recommends continuing hemodialysis until specific cessation criteria are met (anion gap normalization for ethylene glycol, undetectable or very low toxin levels) 4

Assess for life-threatening complications requiring immediate intervention, such as altered mental status, seizures, severe metabolic acidosis, refractory shock, or respiratory failure, and obtain stat laboratory studies, including serum toxin levels, arterial blood gas, anion gap, osmol gap, electrolytes, renal function, and lactate, according to the Critical Care society 5

Initiate hemodialysis immediately for ethylene glycol poisoning with glycolate concentration >12 mmol/L, anion gap >27 mmol/L, coma or seizures, or acute kidney injury, as recommended by the Critical Care society 5
Initiate hemodialysis for beta-blocker toxicity with refractory bradycardia or hypotension despite vasopressors, need for extracorporeal life support, or severe toxicity from hydrophilic beta-blockers, according to the Critical Care society 6

Use intermittent hemodialysis as first-line therapy over all other extracorporeal modalities, and optimize technical parameters, such as high-flux dialyzers, maximal blood flow rates, and optimal dialysate flow rates, as recommended by the Critical Care society 5, 6
Lower dialysate temperature to minimize hemodynamic compromise in unstable patients, according to the Critical Care society 6

Maintain serum magnesium >1 mmol/L and potassium 4.5-5 mmol/L during dialysis for sotalol poisoning, and add magnesium to dialysate or administer intravenously to prevent torsades de pointes, as recommended by the Critical Care society 6

Do not stop hemodialysis based solely on toxin concentration; continue until clinical improvement and specific biochemical targets are met, such as anion gap <18 mmol/L for ethylene glycol poisoning, according to the Critical Care society 5, 6