To enquiry, he admitted taking Ayurvedic medicine over a long but unquantifiable duration. This was preceded by eight months of polyarthralgia, constipation, abdominal pain, and nausea and vomiting, and one month of severe neuropathic pain in all limbs, nightmares and involuntary vocalization. He presented with progressive global motor weakness, tremor and hallucinations in December 2011. ![]() There was only a partial response to ciclosporin, and he reached end-stage kidney failure requiring hemodialysis in August 2011. We describe an instructive case and review the relevant literature, thereby providing general guidance on the timing, type, dose and duration of both chelation therapy during EBP for heavy metal poisoning in anuric patients.Ī 28-year-old man on maintenance hemodialysis (HD) was diagnosed with steroid-resistant primary focal segmental glomerulosclerosis causing nephrotic syndrome in February 2006. ![]() For a clinician facing such a case in clinical practice, choosing the right chelating agent for a given patient can be daunting. Although these general principles are well known, there is only a small published literature reporting a wide range of practices often without clear links to outcomes. When using EBP, chelating agents are generally mandatory to achieve rapid removal and meaningful detoxification. In patients who are anuric, whether from acute kidney injury (AKI) or end-stage kidney failure (ESKF), EBP is the only means for removal of heavy metals, and a critical intervention alongside general measures to support and preserve organ function. So long as renal function is not severely impaired, treatment of poisoning does not normally require adjunctive extracorporeal blood purification (EBP), which is inferior to removal of heavy metals by normally functioning kidneys. The most common agents are dimercaprol, also known as British Anti-Lewisite (BAL) calcium-disodium-ethylenediaminetetraacetic acid (CaNa 2EDTA) dimercaptosuccinic acid, also known as succinmer (DMSA) and 2,3-Dimercapto-1-propanesulfonate (DMPS). ![]() The major route of elimination of heavy metals is usually through the kidneys, and in cases of poisoning this elimination can be enhanced by chelating agents. Heavy metal poisoning involving arsenic (Ars) and lead (Pb) can cause debilitation and death.
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