Hyperchloremic metabolic acidosis after plasma exchange in a patient with renal transplant rejection: A case report.

Therapeutic plasma exchange (TPE) is an effective treatment for several renal disorders, including renal transplant rejection. However, repeated plasma exchanges can result in various metabolic disturbances and complications. We present a 61-year old male with a medical history of type 2 diabetes, hypertension, successfully treated multiple myeloma, and a post-mortem kidney transplantation 7 months prior to presentation. The patient was hospitalized with an antibody-mediated transplant rejection for which treatment with methylprednisolone, TPE with a 40 g/L albumin solution as a replacement fluid, and intravenous immunoglobulins was initiated. After four TPE treatments, the patient developed gastrointestinal complaints and muscle weakness. Despite daily oral bicarbonate supplementation, laboratory tests revealed a hyperchloremic metabolic acidosis: bicarbonate 11.7 mmol/L, chloride 111 mmol/L, and sodium 138 mmol/L. Metabolic acidosis due to citrate accumulation was ruled out with a normal total-to-ionized calcium ratio. After treatment with intravenous bicarbonate supplementation, the symptoms disappeared. Analysis of the albumin solution showed a chloride concentration of 132 mmol/L. This is the first case that describes severe metabolic acidosis after multiple sessions of TPE with an albumin solution in a patient with impaired renal function. The hyperchloremic metabolic acidosis is the result of administration of large volumes of an albumin solution with high chloride concentrations. Special attention should be paid to the acid-base balance during TPE in patients with impaired renal function. Future research should investigate the incidence of hyperchloremic metabolic acidosis during TPE in patients with impaired renal function.

Novel Ureteral Stent Catheterization Technique for Treating Hyperchloremic Metabolic Acidosis After Total Pelvic Exenteration.

BACKGROUND/AIM: Hyperchloremic metabolic acidosis after total pelvic exenteration (TPE) is relatively rare. Urinary diversion of the ileal conduit during TPE can result in increased urine reabsorption leading to hyperchloremic metabolic acidosis. We developed a new technique for the retrograde catheterization of a ureteral stent into an ileal conduit to treat hyperchloremic metabolic acidosis. CASE REPORT: A 70-year-old man underwent TPE for locally recurrent rectal cancer. Multiple episodes of complications, such as hyperchloremia and metabolic acidosis, occurred. Effective drainage of urine from the ileal conduit is crucial. With collaboration between an endoscopist and a radiologist, we developed a novel method for retrograde catheterization of the ureteral stent into an ileal conduit for hyperchloremic metabolic acidosis after TPE. The patient's condition quickly improved after the procedure. CONCLUSION: Our novel technique of retrograde catheterization of a ureteral stent into an ileal conduit for hyperchloremic metabolic acidosis could be adopted worldwide, as it is effective and safe.

Metabolic acidosis after ileal urinary diversion and radical cystectomy. Do we know as much as we think we do? A systematic review.

Urine contact with the mucosa of the urinary diversion (UD) after radical cystectomy (RC) produces different ion exchanges that favor the development of metabolic acidosis (MA). This phenomenon is a frequent cause of hospital readmission and short/long-term complications. We performed a systematic review of MA in RCs with ileal UD, analyzing its prevalence, diagnosis, risk factors and treatment. We systematically searched Pubmed® and Cochrane Library for original articles published before May 2022 according to PRISMA guidelines. A total of 421 articles were identified. We selected 25 studies that met the inclusion criteria involving 5811 patients. Obtaining precise data on the prevalence of MA is difficult, largely due to the heterogeneity of the diagnostic criteria used given the diversity of studies analyzed. Development of MA is multifactorial. In the early period, MA is more prevalent in patients with UD with longer ileal segments, better urinary continence, and impaired renal function. Age and diabetes are risk factors associated with MA in later periods. MA is the most common cause of second or more hospital readmissions. Prophylaxis with oral bicarbonate for three months in patients at risk could improve these results. Although MA after ileal UD is a well-known condition, this review highlights the need to implement homogeneous criteria for the diagnosis, follow-up, and treatment, in addition to protocolizing prevention/prophylaxis strategies in patients at risk.

Hemorrhagic, hypovolemic shock resuscitated with Ringer's solution using bicarbonate versus lactate: A CONSORT-randomized controlled study comparing patient outcomes and blood inflammatory factors.

BACKGROUND: Isotonic crystalloids are the preferred solution for the initial clinical management of patients with multiple trauma, among which lactated Ringer's solution and normal saline are the most widely used, but both have clinical limitations. Bicarbonated Ringer's solution (BRS), which provides physiological levels of bicarbonate ions and electrolyte ions, can be used to supplement missing extracellular fluid and correct metabolic acidosis. METHODS: A prospective, randomized controlled study enrolled 63 patients with traumatic hepatic rupture and hemorrhagic shock. They were randomly assigned to the Bicarbonated group (n = 33) or the Control group (n = 30), which received restrictive fluid resuscitation with sodium bicarbonate Ringer's solution or sodium lactate Ringer's solution, respectively. The levels of interleukin (IL)-6, tumor necrosis factor (TNF)-α, arterial blood lactic acid and potential of hydrogen (pH) were measured prior to, 1, 3, 24, and 72 hours following resuscitation. The primary outcomes were patient survival, shock-related complications, and comparison of the inflammatory factors. RESULTS: The incidence of complications in the Bicarbonated group was significantly lower than in the Control group (15.15% vs 40.0%; P < .05). The intensive care unit length of stay and mechanical ventilation time in the Bicarbonated group were significantly shorter than in the Control group (all P < .01). The levels of IL-6 and TNF-α in the Bicarbonated group were significantly lower 1 hour following resuscitation than prior to resuscitation (P < .01), whereas these levels in the Control group were increased following 1h of resuscitation as compared with before resuscitation (P < .01). Following resuscitation, the levels of IL-6, TNF-α and lactate in the Bicarbonated group were significantly lower than in the Control group (P < .01). Moreover, in the Bicarbonated group, the lactic acid level decreased and the pH value increased significantly following resuscitation, whereas there was no difference in lactic acid levels and pH value between pre- and 1 hour post-resuscitation in the Control group (P > .05). CONCLUSION: The shock-related complications were dramatically reduced from using BRS in these patients. Additionally, the BRS was found to better inhibit the expression of inflammatory factors in their peripheral blood and could correct acidosis.

Elevated international normalized ratio is correlated with large volume transfusion in pediatric trauma patients.

BACKGROUND: Pediatric trauma patients may benefit from a balanced transfusion strategy, however, determining when to activate massive transfusion protocols remains uncertain. The purpose of this study was to explore whether certain scoring systems can predict the need for large volume transfusion. METHODS: We conducted a retrospective review of pediatric trauma patients who presented to our center and required a transfusion of packed red blood cells. Baseline laboratory and clinical data were used to calculate Trauma Associated Severe Hemorrhage (TASH) score and a previously reported composite of acidosis and coagulopathy. RESULTS: We identified 518 pediatric trauma patients who presented to our center between January 1, 2013 and December 31, 2018. These patients were less than 18 years of age (mean 9.6 years) and had an injury severity score ranging from 1 to 50 (mean 11.3). Forty-three patients (8.3%) received a transfusion within 24 hours of presentation, ranging from 4 to 139 mL/kg of packed red blood cells (mean 23.1 mL/kg). Transfusion volume was associated with acidosis and coagulopathy scores (r = 0.37, p = 0.033) and international normalized ratio (INR) (r = 0.34, p = 0.03) but not TASH (p = 0.72). Patients with INR≥1.3 received a higher mean volume of packed red cells compared to those with normal values (34 versus 18 mL/kg, p = 0.046). CONCLUSION: Pediatric trauma patients who undergo transfusion of packed red blood cells are likely to require large volume transfusion if their baseline INR is ≥1.3. These patients may benefit from a balanced transfusion strategy, such as utilization of massive transfusion protocols or whole blood.

[A case of severe ethylene glycol poisoning treated successfully by V-V ECMO combined with blood purification].

Ethylene glycol, also known as glycol, is a common low-temperature antifreeze used in automobiles. It is a colorless, odorless, volatile, low-sweet, sticky liquid at room temperature. Ethylene glycol is easily decomposed and absorbed through the digestive tract. Toxic metabolites cause serious clinical symptoms such as central nervous system inhibition, metabolic acidosis, cardiopulmonary symptoms and renal insufficiency, and even death. Misuse and oral suicide are the main causes of ethylene glycol poisoning. This article reports a case of severe ethylene glycol poisoning admitted to the emergency department of the Affiliated Hospital of Hangzhou Normal University in December 2021. After treatment with V-V ECMO combined with blood purification, the patient was improved and discharged from hospital.

Fulminant Bacillus cereus food poisoning with fatal multi-organ failure.

This case represents a rare fulminant course of fried-rice associated food poisoning in an immunocompetent person due to pre-formed exotoxin produced by Bacillus cereus, with severe manifestations of sepsis, including multi-organ (hepatic, renal, cardiac, respiratory and neurological) failure, shock, metabolic acidosis, rhabdomyolysis and coagulopathy. Despite maximal supportive measures (continuous renal replacement therapy, plasmapheresis, N-acetylcysteine infusion and blood products, and broad-spectrum antimicrobials) and input from a multidisciplinary team (consisting of infectious diseases, intensive care, gastroenterology, surgery, toxicology, immunology and haematology), mortality resulted. This case is the first to use whole genome sequencing techniques to confirm the toxigenic potential of B. cereus It has important implications for food preparation and storage, particularly given its occurrence in home isolation during the COVID-19 pandemic.

Theophylline toxicity: Successful management of a patient with distributive shock secondary to drug overdose.

Presenting a case of acute theophylline and salbutamol overdose with distributive shock. Twenty one years old lady presented with history of consumption of 3 gram of theophylline and 40 mg of salbutamol. On admission she had altered sensorium with the systolic blood pressure of 60 mmHg, unrecordable diastolic blood pressure and heart rate of 147/min. Investigations revealed severe metabolic acidosis, hypokalemia, hypocalcemia which was managed by intravenous fluids, vasopressors, infusion of injection calcium gluconate and injection potassium chloride. As her hemodynamic status did not improve, she has been initiated on 1.5 mL/kg of lipid emulsion as bolus and then 0.5 mL/kg/h as infusion. Her hemodynamic status improved gradually and she was discharged in 24 h. Lipid emulsion had been used in local anesthetics and many tablet overdoses. In this patient timely administration of lipid emulsion resulted in early recovery of shock.

Successful Intensive Care Treatment of Severe Lactic Acidosis and Tumor Lysis Syndrome Related to Intravascular Lymphoma.

Intravascular lymphoma is a rare disease that progresses to multiple organ dysfunction caused primarily by tumor cell proliferation in small blood vessels. Few studies have investigated critical care management of intravascular lymphoma. We describe a rare case of multiple organ failure due to intravascular lymphoma with severe lactic acidosis in a patient who survived. A 64-year-old man with impaired consciousness was diagnosed as having intravascular large B-cell lymphoma by means of a random skin biopsy. The patient arrived at our hospital's intensive care unit (ICU) with impaired consciousness, respiratory failure that required mechanical ventilation, and lactic acidosis that required renal replacement therapy. Mechanical ventilation and renal replacement therapy were continued in the ICU, and his respiratory status and circulatory dynamics eventually stabilized. However, his impaired consciousness and hyperlactatemia did not improve until after the start of chemotherapy with doxorubicin, cyclophosphamide, vincristine, prednisolone, and rituximab. Although he developed tumor lysis syndrome immediately after chemotherapy, his systemic condition was gradually stabilized by continued critical care management primarily comprising renal replacement therapy. He was weaned from ventilator support after a tracheotomy and moved to the general ward. Hematopoietic malignancy with hyperlactatemia has a very poor prognosis; however, hyperlactatemia and impaired consciousness were dramatically improved in this patient by critical care management and chemotherapy.

Brief report: Metabolic acidosis in newborn infants following maternal use of acetazolamide during pregnancy.

 The information regarding fetal effects of acetazolamide use during pregnancy and lactation is sparse. We report the clinical and pharmacodynamic characteristics of maternal acetazolamide use and the timing of its effects on acid-base balance in three cases who presented with metabolic acidosis in the newborn period. We found that the infants' clinical status soon after birth was inconsistently correlated with maternal drug dose and concentrations of medication in maternal serum. However, there was low transfer of the drug in breast milk and its use did not affect clinical symptomatology. We also present a review of literature on this subject to help consolidate our current knowledge on this topic.

Zero balance ultrafiltration using dialysate during nationwide bicarbonate shortage: a retrospective analysis.

BACKGROUND: Zero balance ultrafiltration (Z-BUF) utilizing injectable 8.4% sodium bicarbonate is utilized to treat hyperkalemia and metabolic acidosis associated with cardiopulmonary bypass (CPB). The nationwide shortage of injectable 8.4% sodium bicarbonate in 2017 created a predicament for the care of cardiac surgery patients. Given the uncertainty of availability of sodium bicarbonate solutions, our center pro-actively sought a solution to the sodium bicarbonate shortage by performing Z-BUF with dialysate (Z-BUF-D) replacement fluid for patients undergoing cardiopulmonary bypass. METHODS: Single-center, retrospective observational evaluation of the first 46 patients at an academic medical center who underwent Z-BUF using dialysate over a period of 150 days with comparison of these findings to a historical group of 39 patients who underwent Z-BUF with sodium chloride (Z-BUF-S) over the preceding 150 days. The primary outcome was the change in whole blood potassium levels pre- and post-Z-BUF-D. Secondary outcomes included changes in pre- and post-Z-BUF-D serum bicarbonate levels and the amount of serum bicarbonate used in each Z-BUF cohort (Z-BUF-D and Z-BUF-S). RESULTS: Z-BUF-D and Z-BUF-S both significantly reduced potassium levels during CPB. However, Z-BUF-D resulted in a significantly decreased need for supplemental 8.4% sodium bicarbonate administration during CPB (52 mEq ± 48 vs. 159 mEq ± 85, P < 0.01). There were no complications directly attributed to the Z-BUF procedure. CONCLUSION: Z-BUF with dialysate appears to be analternative to Z-BUF with sodium chloride with marked lower utilization of intravenous sodium bicarbonate.

Ethylene glycol intoxication following brake fluid ingestion complicated with unilateral facial nerve palsy: a case report.

BACKGROUND: Brake oil is an automobile transmission fluid composed of a mixture of toxic alcohols such as ethylene glycols and glycol ethers. Both accidental and intentional ingestion cases have been reported and they can present with multisystem involvement. Life-threatening complications evolve from deleterious effects on cardiopulmonary and renal systems. Effects on neurological and gastrointestinal systems give rise to a multitude of complications although non-fatal in nature. The biochemical panel consists of a high concentration of ethylene glycol with severe metabolic acidosis, high anion gap, high osmolar gap, oxaluria, and hypocalcemia. The mainstay of treatment is enhanced elimination of ethylene glycol and its metabolites by hemodialysis, together with general supportive care, gastric decontamination, and vitamins such as thiamine and pyridoxine to minimize the adverse effects of intoxication. CASE PRESENTATION: A 26-year-old Sinhalese woman presented with reduced urine output, shortness of breath, reduced level of consciousness, abdominal pain, and vomiting with mild degree fever of 2 days' duration. She had bilateral lower limb edema, crepitations over bilateral lower lung fields, and right-sided lower motor type facial nerve palsy. Investigations showed severe metabolic acidosis with high anion gap and high osmolar gap. With regular hemodialysis she made a complete recovery after 3 months. CONCLUSION: Even without a clear history of poisoning, the presence of a high anion, high osmolar gap metabolic acidosis should prompt one to search for ethylene glycol ingestion. Uncommon manifestations like cranial neuropathies need to be examined and considered. Timely aggressive treatment leads to a better prognosis.

An Under-Recognised Cause of Iatrogenic, Severe Metabolic Acidosis

Case Pyroglutamic acidosis is an uncommonly diagnosed but important cause of a high anion gap metabolic acidosis. Our case report concerns an elderly male admitted to the Intensive Care Unit (ICU) following the acute onset of coma which developed during treatment of a prosthetic joint infection. A diagnosis of pyroglutamic acidosis was ultimately made and later confirmed with laboratory testing. Blood gas analysis revealed a profound high anion gap metabolic acidosis. Treatment Treatment included withdrawal of the precipitating medications, N-acetylcysteine and sodium bicarbonate. Discussion This case highlights an unusual cause of severe metabolic acidosis caused by commonly used medications and readily reversible if recognised. This is of particular relevance in elderly, frail patients as incorrect alternate diagnoses may result in decisions which incorrectly limit critical care therapies.

Young man with severe metabolic acidosis after transformer oil ingestion: a case report.

BACKGROUND: Transformer oil is used in oil-filled transformers for its insulating as well as coolant properties. Transformer oil ingestion for attempted suicide is seldom heard of. Our patient's case presented us with a major diagnostic as well as treatment challenge because we encountered such a case for the first time and were totally unaware of the fact that methanol might make up the main component of an aged transformer oil. CASE PRESENTATION: A 19-year-old Pakistani/Asian man was brought to our hospital with altered sensorium. He was found to have elevated anion gap acidosis, increased osmolal gap, and acute kidney injury. He had no evidence of rhabdomyolysis or hemolysis. Computed tomography of his head showed cerebral edema. He was resuscitated with intravenous fluids and bicarbonate. Three days later, he confessed taking transformer oil with suicidal intention. His clinical picture mimicked acute methanol intoxication. With an initial improvement in his neurological status, he started complaining of constant headache with episodes of agitation and delirium. His renal function continued worsening despite an adequate urine output. He showed a remarkable improvement in his neurological state after just one session of hemodialysis. CONCLUSIONS: There is evidence that aged transformer oil contains methanol, and a patient who consumes it can present with features mimicking acute methanol intoxication.

[CME: Ethylene Glycol Intoxication]. / CME: Ethylenglykol-Intoxikation.

CME: Ethylene Glycol Intoxication Abstract. Ethylene glycol is a sweet-tasting alcohol used in common antifreeze and other industrial solutions. Without appropriate therapy, intoxication with ethylene glycol can result in severe metabolic acidosis, acute renal failure, and in death. After gastrointestinal resorption, hepatic metabolism starts with oxidation by alcohol dehydrogenase and results in severe anion gap metabolic acidosis. Other metabolic products are calcium oxalate crystals, which can deposit in several tissues like the kidneys and lead to acute tubular necrosis with reversible renal failure. The crucial therapeutic step is rapid inhibition of alcohol dehydrogenase with fomepizole or ethanol to avoid the formation of toxic metabolites. Additionally, haemodialysis is the most effective way to eliminate ethylene glycol as well as its toxic metabolites. If therapy is initiated rapidly, prognosis is favorable.

Impacto del componente hiperclorémico de la acidosis metabólica en el estado de hidratación y en el tratamiento de la cetoacidosis diabética / Impact of the hyperchloremic component of metabolic acidosis on the patient's hydration status and the treatment of diabetic ketoacidosis

Introducción. La cetoacidosis diabética (CAD) se caracteriza por acidosis metabólica (AM) con anión restante (AR) elevado, aunque, ocasionalmente, puede presentar hipercloremia. Se postuló que la presencia de hipercloremia inicial podría reflejar un mejor estado de hidratación; sin embargo, su prevalencia y su impacto en el tratamiento de la CAD se desconoce. Objetivos. Determinar la prevalencia de AM con componente hiperclorémico previo al inicio del tratamiento y evaluar si su presencia se asocia con mejor estado de hidratación y con menor tiempo de salida de la CAD, en comparación con los pacientes con AR elevado exclusivo. Pacientes y métodos. Se agruparon los pacientes internados con CAD (período entre enero de 2014 y junio de 2016) según presentaran, al ingresar, AM con AR elevado exclusivo o con hipercloremia y se compararon sus variables clínicas, de laboratorio y la respuesta al tratamiento. Resultados. Se incluyeron 40 pacientes -amp;#91;17 varones, mediana de edad: 14,5 años (2,4-18)-amp;#93;, 22 con AM con componente hiperclorémico (prevalencia de 55%) y 18 con AR elevado exclusivo. La presencia de hipercloremia no se asoció con mejor estado de hidratación (porcentaje de déficit de peso en ambos grupos: 4,9%; p= 0,81) ni con una respuesta terapéutica más rápida (con componente hiperclorémico: 9,5 horas; con AR elevado exclusivo: 11 horas; p= 0,64). Conclusiones. En niños con CAD, la prevalencia de AM con componente hiperclorémico fue del 55% y no se asoció con un mejor estado de hidratación ni con una salida más temprana de la descompensación metabólica.

Introduction. Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis (MA) with a high anion gap (AG), although, occasionally, it can present with hyperchloremia. It has been postulated that the early presence of hyperchloremia could reflect a better hydration status; however, its prevalence and impact on DKA treatment remain unknown. Objectives. To determine the prevalence of the hyperchloremic component in MA prior to treatment and to assess whether it is associated with a better hydration status and a shorter recovery time from DKA compared to patients with high AG only. Patients and Methods. Patients hospitalized with DKA (between January 2014 and June 2016) were grouped according to whether they were admitted with MA with high AG only. or with hyperchloremia, and clinical and laboratory outcome measures and response to treatment were compared. Results. Forty patients (17 males, median age: 14.5 years -amp;#91;2.4-18-amp;#93;) were included; 22 with hyperchloremic metabolic acidosis (prevalence of 55%) and 18 with metabolic acidosis with high AG only. The presence of hyperchloremia was not associated with a better hydration status (weight loss percentage in both groups: 4.9%; p= 0.81) nor with a faster treatment response (MA with a hyperchloremic component: 9.5 hours; MA with high AG only: 11 hours; p= 0.64). Conclusions. The prevalence of MA with a hyperchloremic component among children with DKA was 55% and was not associated with a better hydration status nor with a faster recovery from the metabolic decompensation.

Fresh red blood cells transfusion protects against aluminum phosphide-induced metabolic acidosis and mortality in rats.

BACKGROUND: Aluminum phosphide (AlP) is used as pesticide in some countries for protection of stored grains. Human poisoning with AlP due to suicide attempt or accidental environmental exposure is associated with very high mortality partially due to development of severe metabolic acidosis. Previous studies have shown that hemoglobin has high buffering capacity and erythrocytes can potentially be used for management of metabolic acidosis. The aim of this study was to evaluate the effect of fresh packed red blood cells (RBC) transfusion on survival and cardiovascular function in AlP-poisoned rats. METHODOLOGY/PRINCIPAL FINDINGS: Rats were poisoned with AlP by gavage. Fresh packed RBC was transfused via tail vein after AlP administration. Acid-base balance, vital signs and mortality was assessed and compared in experimental groups. Infusion of fresh packed RBC (1.5 ml) one hour after AlP (4-15 mg/kg) intoxication was associated with a significant decrease in mortality rate. Packed RBC infusion improved blood pH, HCO3-, Na+ and Ca2+ levels. Plasma troponin level was also reduced and ECG changes were reversed following packed RBC infusion in AlP intoxicated rats. CONCLUSIONS: Our results showed that fresh RBC transfusion could ameliorate metabolic acidosis and enhance survival in AlP-poisoned rat. We assume that an increase in pool of RBCs may modulate acid-base balance or potentially chelate AlP-related toxic intermediates via phosphine-hemoglobin interaction.