Activated charcoal helps in the diagnosis of dabigatran overdose: A case study.

The direct-acting oral anticoagulant dabigatran etexilate (DE) targets thrombin and is used widely to prevent thromboembolism. A 79-year-old man was admitted to the Emergency Department due to anuria for 2 days. An urgent laboratory examination revealed a serum creatinine concentration of 888 µmol/L. He was diagnosed with acute exacerbation of chronic renal insufficiency. During continuous renal replacement therapy (CRRT), the coagulation test showed a severe reduction in the fibrinogen level as well as a significantly prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT). The patient had been taking DE (110 mg twice daily) for a long time and had not suspended the medication or reduced the dose during the worsening of anuria. Therefore, it should be evaluated before considering plasma replacement therapy for the patient, whether the abnormal coagulation parameters were induced by interference of excessive DE. Tentatively, we used activated charcoal to treat the plasma and then retested the fibrinogen, PT, and APTT. Results showed that the coagulation indices nearly returned to normal. The present case indicated that activated charcoal could adsorb DE in plasma effectively and eliminate its interference with coagulation test results, thereby providing support for clinical diagnosis and treatment.

Acidosis láctica asociada a metformina: incidencia, diagnóstico, factores pronóstico y tratamiento / Metformin-associated lactic acidosis: incidence, diagnosis, prognostic factors and treatment

Describimos el caso de un paciente con acidosis láctica grave y presentamos algunos datos acerca de su incidencia, diagnóstico, factores pronósticos y tratamiento más adecuado. Un paciente varón de 76 años diabético en tratamiento con metformina, hipertenso, dislipémico y con ligero deterioro cognitivo, ingresó en la Unidad de Cuidados Intensivos en estado de shock circulatorio requiriendo tratamiento agresivo con vasopresores y volumen. El paciente presentaba un daño renal agudo con anuria de 3 días probablemente secundario a la deshidratación por vómitos y a la toma de AINES. A consecuencia del daño renal agudo el paciente padeció una acidosis láctica grave asociada a metformina. Se descartó el resto de causas de acidosis metabólica con anion gap aumentado, así como una posible sepsis o rabdomiolisis. La acidosis láctica asociada a metformina es una condición metabólica poco frecuente pero de alta mortalidad. Para disminuir la mortalidad de estos pacientes, es importante hacer un diagnóstico precoz mediante la historia clínica, la exploración física y la analítica con una rápida reanimación mediante volumen, vasopresores, bicarbonato y técnica de depuración extra-renal(AU)

We describe the case of a patient with severe lactic acidosis, as well as presenting some data on its incidence, diagnosis, prognostic factors, and the most appropriate treatment. A 76 year-old male patient with diabetes on treatment with metformin, hypertension, dyslipaemia, and with mild cognitive impairment, was admitted to the Intensive Care Unit in a state of circulatory shock, requiring aggressive treatment with vasopressors and volume. The patient had acute kidney injury with an anuria of 3 days, probably secondary to dehydration to vomiting and to NSAIDs. As a result of the acute renal damage, the patient suffered a severe metformin-associated lactic acidosis. The rest of the causes of metabolic acidosis with an increased anion gap were ruled out, as well as a possible sepsis or rhabdomyolysis. Metformin-associated lactic acidosis is an uncommon metabolic condition, but with a high mortality. To reduce the mortality of these patients, it is important to make an early diagnosis using the clinical records, physical examination, and laboratory tests, with an early resuscitation with volume, vasopressors, bicarbonate, and renal replacement therapy(AU)

Fracaso renal agudo anúrico secundario a tratamiento con acetazolamida / Anuric acute renal failure due to acetazolamide

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Rabdomiólisis y fracaso renal anúrico inducidos por el tratamiento combinado de gemfibrozil y cerivastatina / Rhabdomyolysis and acute renal failure due to combined therapy with gemfibrozil and cerivastatin

Un paciente de 67 años en tratamiento con gemfibrozil durante un año desarrolló una rabdomiólisis con un fracaso renal anúrico al añadirse cerivastatina. La historia clínica y las investigaciones serológicas descartaron razonablemente otras causas de rabdomiólisis. Se suspendió la medicación y se inició hemodiálisis hasta que reapareció la diuresis 14 días después. La función renal mejoró progresivamente hasta una creatinina de 1,2 mg/dl a los dos meses. La cerivastatina por superfil farmacocinético presenta menor capacidad de interacción farmacológica que otras estatinas. El desarrollo de rabdomiólisis y fracaso renal agudo secundario a la combinación de fibratos y cerivastatina, es una complicación infrecuente ya que sólo existen dos casos. Este paciente ilustra la potencial gravedad de la asociación de fibratos y cerivastatina. Cuando se precise esta asociación es necesario evitar otros agentes nefrotóxicos y miopáticos así como controlar periódicamente la CK (AU)

A 67-year-old man treated with gemfibrozil for a year development rhabdomyolysis and anuric renal failure after addition of cerivastatin. The clinical features and serological studies ruled out other causes of rhabdomyolysis. Drugs were stopped and hemodialysis was carried on for 14 days until diuresis occurred. The renal function improved steadily to a serum creatinine of 1.2 mg/dl two monthslater. On the basis of its pharmacokinetic profile cerivastat in appears to have less interactions than other statins. There are only two reports of rhabdomyolysis and acute renal failure due to fibrates and cerivastatin combination. This patient shows the potential risk of a fibrates-cerivastatin combination. When this association is required it is necessary to avoid other nephrotoxic and myopathic factors and to monitor CK levels closely (AU)