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Abstract: SA-PO656

Time for a(n Ex)Change: Treatment of Acute Cardiac Glycoside Intoxication with Extracorporeal Fab-Glycoside Removal in the Setting of Oliguria or Anuria: Experience from Two Cases Treated with TPE

Session Information

Category: Pharmacokinetics, Pharmacodynamics, and Pharmacogenetics

  • 1601 Pharmacokinetics, Pharmacodynamics, Pharmacogenomics


  • Balzer, Michael S., Hannover Medical School, Hannover, Germany
  • Stahl, Klaus, Hannover Medical School, Hannover, Germany
  • Fleig, Susanne V., Hannover Medical School, Hannover, Germany
  • David, Sascha, Hannover Medical School, Hannover, Germany
  • Haller, Hermann G., Hannover Medical School, Hannover, Germany

Anti-cardiac glycoside-antibody-fragments (Fab) (46kDa) are the only approved treatment for severe digitoxin intoxication. Simplified binding of the Fab to the glycoside inhibits its therapeutic effects and facilitates its renal excretion. Therefore, sustaining effectiveness of this detoxification strategy requires a certain glomerular filtration rate. It becomes obvious that in acute kidney injury (AKI) or chronic kidney disease (CKD) scenarios this elimination efficacy might be negatively affected. Removal of the Fab-glycoside complex by conventional hemodialysis is not efficient.


We here report 1 case of a patient with oliguric AKI and 1 case of an anuric patient with CKD stage 5D, both with symptomatic digitoxin intoxication. Treatment with Fab was complemented by subsequent elimination of the Fab-glycoside complex using either therapeutic plasma exchange (TPE) alone or a combination of TPE and high cut-off (HCO) dialysis. Digitoxin serum levels prior to, during and after the different treatment regimens are presented in Figure 1 and include a kinetic time course during TPE for the anuric patient.


TPE appeared to be much more efficient in reducing digitoxin serum levels than HCO dialysis. This was most likely due to the high extent of plasma protein binding of digitoxin. As demonstrated by these 2 cases, we suggest to consider extracorporal Fab-glycoside removal to prevent rebound toxicity following Fab treatment in severe cardiac glycoside intoxication in oliguric or anuric patients. While it has still to be demonstrated that HCO dialysis is efficient in digoxin intoxication, TPE might be the preferred treatment modality in digitoxin intoxication.