Efficacy of sustained low-efficiency dialysis in the management of topiramate intoxication: case report

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Silvia Barbarini

Silvia Barbarini1, Vilma Martella1, Emiliana Ferramosca1, Paolo Ria1, Anna Zito1, M.Luisa Lefons1, Maria Caterina Carbonara1, Giulia Fontò1,  Paolo Protopapa1,  Antonio De Pascalis1, Marcello Napoli1

1 Ospedale Vito Fazzi, Lecce, Italia. Dipartimento di nefrologia, dialisi e trapianto

Corresponding author:
Silvia Barbarini
Nefrologia Dialisi e Trapianto
Ospedale Vito Fazzi
Piazza Filippo Muratore, 1
73100, Lecce
Tel: 0832/661530
E-mail: silvia.barbarini@libero.it

 

Abstract

Guidelines on the use of dialysis treatment in patients with chronic kidney disease (CKD) and TPM (Topiramate) intoxication are controversial. A 51-year-old man with epilepsy and CKD was carried to our emergency department for dysuria and sickness. He chronically assumed TPM 100 mg 3/day. Creatinine level was 2.1 mg/dL, blood urea nitrogen 70 mg/dL, and inflammation indexes were increased.

We started empirical antibiotic therapy and rehydration. The day two he had diarrhea and an acute insurgence of dizziness, confusion, and bicarbonate levels reduction. Brain CT resulted negative for acute events. During the night his mental status worsened, and urinary output results were about 200 mL in 12h. EEG showed desynchronized brain bioelectric activity. Thereafter, there was an episode of seizure and then anuria, hemodynamic instability, and loss of consciousness. Creatinine value was 5.39 mg/dL with a serious metabolic acidosis non-anion gap. We decided to start 6-hours Sustained Low Efficiency Hemo-Dia-Filtration (SLE-HDF). We assisted in the recovery of consciousness and later in the improvement of kidney function after 4 hours of treatment. TPM levels before SLE-HDF resulted in 123.1 µg/mL. At the end of treatment resulted in 30 µg/mL. To our knowledge, this is the first report of TPM involuntary intoxication in a patient affected by CKD who survived such a high TPM concentration treated with renal replacement therapy. SLE-HDF resulted in moderate elimination of TPM and acidemia resolution, continuous monitoring patient’s vital parameters in relation to his hemodynamic instability, since blood flow and dialysate flow are lower than conventional hemodialysis.

Keywords: Intoxication, Sustained Low-efficiency dialysis, hemodialysis, metabolic acidosis, continuous venovenous haemofiltration

Introduction

Topiramate (TPM) is an anticonvulsant agent indicated according to American Academy of Neurology (AAN) guidelines as an adjunct therapy for the treatment of focal and mixed seizures, Lennox-Gastaut syndrome, and as monotherapy for refractory generalized tonic-clonic seizures in adults and children. At steady-state concentration, renal clearance of this drug is 1.02 L/h and its elimination half-life (T1/2) varies from 20 to 30 h. In all species, TPM is predominantly excreted unchanged in the urine [1].

Guidelines on the use of dialysis treatment in patients with chronic kidney disease and topiramate intoxication are controversial. We describe a case of topiramate overdose treated with sustained low-efficiency dialysis (SLED). 

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Metformin and Diabetes: still has a sense of its use in paz. CKD stage II or is an additional risk factor?

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Antonio Pontoriero1, Antonino Saporita1, Carlo Alberto Ricciardi2, Biagio R Ricciardi1

1 U.O.C. di Nefrologia e Dialisi P.O. Milazzo – ASP5 Messina
2 Scuola di Specializzazione in Nefrologia - Università di Messina

Corrispondenza a:
Dott. Antonio Pontoriero
via del Sole n° 30 – 98057 – Milazzo (ME)
cell. 3473655842
e-mail: apontoriero@virgilio.it

 

Abstract

Pz woman of 62 years comes to P.S.G. for fatigue, low-grade fever, diuresis present. A history of hypertension refers to therapy for about five years, diabetes mellitus for about two years in therapy with Metformin 1gr x 3 gg / day.  Blood tests: BUN 195 mg / dL, creatinine 8.0 mg / dl, Ph 6877, HCO3 5.1 mmol / L BE -29.1 mmol / l. Rapid clinical deterioration with occurrence of arterial hypotension – 85/60 mmHg, stupor. Start therapy Bicarbonates ev, is positioned in Urgency CVC and it undergoes AFB with infusion of bicarbonates 2000 ml / h for 4 hours, blood flow rate 250 ml / min., the hemodynamics has been supported with dopamine infusion 200 mg: 2 vials in 250 cc of physiological vel 30 – 40 ml / h, The pc after undergoing three AFB, interrupted the dialysis for resumption of diuresis spontaneous and progressive improvement of renal function and blood pressure. Monitored, after discharge, the parameters of renal function decreased to within normal limits, clearance compatible with IRC II – III stage.

Conclusions: dehydration, fever, IRC II stadium, undiagnosed caused, in a very short time, an accumulation of metformin, which has been the cause of metabolic acidosis. The pc. saved thanks to the positioning of the CVC and to the AFB in the treatment with the infusion of large quantities of Bicarbonates e.v.

The use of metformin in pcs. > 50 years and / or creatinine clearance <60 ml / min., Must be subordinated to the preliminary study and periodic renal function.

 

Keywords: Metformin, Diabetes, IRA, metabolic acidosis

Sorry, this entry is only available in Italian.

Paziente di sesso femminile di 62 anni giunge al P.S.G. per astenia, malessere generale e riferita febbricola, in anamnesi riferisce ipertensione arteriosa in terapia antipertensiva da circa 5 anni, diabete mellito non insulino dipendente da circa 2 anni in terapia con Metformina 1 gr x 3/die. 

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