Hemoperfusion for paraquat poisoning

Abstract

We read with interest the article by Ghannoum et al.,1Ghannoum M. Hoffman R.S. Gosselin S. et al.Use of extracorporeal treatments in the management of poisonings.Kidney Int. 2018; 94: 682-688Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar who analyzed use of extracorporeal treatments in the management of poisonings. The article is comprehensive and stimulating. Ghannoum and colleagues1Ghannoum M. Hoffman R.S. Gosselin S. et al.Use of extracorporeal treatments in the management of poisonings.Kidney Int. 2018; 94: 682-688Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar listed the top five poisons managed via extracorporeal treatment in the US from 2010 to 2014, namely, ethylene glycol, lithium, salicylate, acetaminophen, and ethanol. However, there is no mention of the use of extracorporeal treatment in paraquat poisoning. The reason behind it is not mentioned, probably because of the low incidence of paraquat poisoning in the US. This concerns us because paraquat poisoning is the leading cause of fatal poisoning in Asia. Paraquat poisoning is characterized by acute lung injury, pulmonary fibrosis, respiratory failure, and multiorgan failure, resulting in high mortality and morbidity rates.2Lin J.L. Lin-Tan D.T. Chen K.H. et al.Improved survival in severe paraquat poisoning with repeated pulse therapy of cyclophosphamide and steroids.Intensive Care Med. 2011; 37: 1006-1013Crossref PubMed Scopus (74) Google Scholar Paraquat clearance is apparently more effective with hemoperfusion than with hemodialysis.3Hong S.Y. Yang J.O. Lee E.Y. et al.Effect of haemoperfusion on plasma paraquat concentration in vitro and in vivo.Toxicol Ind Health. 2003; 19: 17-23Crossref PubMed Scopus (54) Google Scholar In a previous study analyzing 207 severely paraquat-poisoned patients,4Hsu C.W. Lin J.L. Lin-Tan D.T. et al.Early hemoperfusion may improve survival of severely paraquat-poisoned patients.PLoS One. 2012; 7: e48397Crossref PubMed Scopus (64) Google Scholar we have demonstrated that early hemoperfusion (less than 4 to 5 hours after ingestion of paraquat) is associated with decreased mortality. According to the paper by Ghannoum et al.,1Ghannoum M. Hoffman R.S. Gosselin S. et al.Use of extracorporeal treatments in the management of poisonings.Kidney Int. 2018; 94: 682-688Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar planned review by EXTRIP (EXtracorporeal TReatment In Poisoning) for paraquat has yet to be completed. As clinical toxicologists in Asia, we look forward to the review. However, we are concerned that there may never be a well-designed evidence-based study in the management of paraquat poisoning because of its urgent need for treatment, as well as its somewhat obscure nature.5Feinfeld D.A. Rosenberg J.W. Winchester J.F. Three controversial issues in extracorporeal toxin removal.Semin Dial. 2006; 19: 358-362Crossref PubMed Scopus (30) Google Scholar Use of extracorporeal treatments in the management of poisoningsKidney InternationalVol. 94Issue 4PreviewHistorically, the clinical application of extracorporeal treatments (ECTRs), such as hemodialysis or hemoperfusion, was first intended for poisoned patients. With time, ECTRs were used almost indiscriminately to facilitate the elimination of many poisons, albeit with uncertain clinical benefit. To determine the precise role of ECTRs in poisoning situations, multiple variables need to be considered including a careful risk assessment, the poison’s characteristics including toxicokinetics, alternative treatments, the patient’s clinical status, and intricacies of available ECTRs, all of which are reviewed in this article. Full-Text PDF Open Archive