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Kidney Week

Abstract: PO0121

Use of Continuous Venovenous Hemodialysis and Plasmapheresis to Treat Simultaneous Iron and Acetaminophen Overdose

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Singh, Tripti, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
  • Nye, Rebecca, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
Introduction

Iron may fatally exacerbate toxicity in polypharmacy overdoses, including acetaminophen overdose. We present a case of intentional acetaminophen and iron overdose and treatment with continuous veno-venous hemofiltration (CVVH) and plasmapheresis.

Case Description

31-year-old male with history of schizophrenia and previous suicide attempts presented to an outside hospital with abdominal pain and emesis 1.5 hours after ingestion of 100 tablets each of 325 mg acetaminophen and 325 mg ferrous sulfate. Vitals on admission were BP 121/83 mmHg, pulse 93 bpm, RR 18/min, O2 saturation 98% on RA. Labs showed bicarbonate 23 mEq/L, anion gap (AG) of 14, BUN 16 mg/dL, creatinine 1 mg/dL, total bilirubin 0.7 mg/dL, AST 24 units/L, ALT 16 units/L, iron 356 ug/dL, and acetaminophen 269.8 ug/mL. Patient was started on IV acetylcysteine. Repeat labs 12 hours later revealed iron level 4326 ug/dL, total bilirubin 4.8 mg/dL, AST 476 units/L, and ALT 855 units/L. IV deferoxamine was initiated. Patient became lethargic and hypotensive and required intubation. He was transferred to our hospital for further management. Labs upon arrival showed AG of 16, bicarbonate of 12 mEq/L, creatinine 1.98 mg/dL, ALT 13129 units/L, AST 7351 units/L, total bilirubin 3.6 mg/dL, ammonia 882 umol/L, acetaminophen 179 ug/mL, iron >900 ug/dL. On physical exam, patient was unresponsive, euvolemic, and NG tube drain was bloody. CVVH was started via left femoral dialysis catheter with blood flow rate of 250 ml/min and replacement fluid rate of 3500 ml/hour. 6 hours after CVVH, labs revealed an iron level of 362 ug/dL and an acetaminophen level of 100 ug/mL. Due to continued deterioration including hemodynamic instability and persistent acidosis, plasmapheresis was initiated. Labs 2 hours later showed iron level of 20 ug/dL and acetaminophen level of 91 ug/mL. The patient’s clinical status continued to decline despite removal of iron and acetaminophen and he died after 24 hours due to fulminant liver failure.

Discussion

In this case of simultaneous massive iron and acetaminophen overdose, CVVH was effective in removal of iron (60%) and acetaminophen (44%) over 6 hours. Plasmapheresis may be considered as an additional modality to remove excess free iron from the blood.