Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada, and Department of Nephrology and Hypertension, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
New South Wales Poisons Information Centre, Sydney Children's Hospitals Network, Westmead, and Edith Collins Centre, Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
Clin J Am Soc Nephrol. 2023 Sep 1;18(9):1210-1221. doi: 10.2215/CJN.0000000000000057. Epub 2023 Jan 13.
Poisoning occurs after exposure to any of a number of substances, including medicines, which can result in severe toxicity including death. The nephrologist may be involved in poisonings that cause kidney disease and for targeted treatments. The overall approach to the poisoned patient involves the initial acute resuscitation and performing a risk assessment, whereby the exposure is considered in terms of the anticipated severity and in the context of the patient's status and treatments that may be required. Time-critical interventions such as gastrointestinal decontamination ( e.g. , activated charcoal) and antidotes are administered when indicated. The nephrologist is usually involved when elimination enhancement techniques are required, such as urine alkalinization or extracorporeal treatments. There is increasing data to guide decision making for the use of extracorporeal treatments in the poisoned patient. Principles to consider are clinical indications such as whether severe toxicity is present, anticipated, and/or will persist and whether the poison will be significantly removed by the extracorporeal treatment. Extracorporeal clearance is maximized for low-molecular weight drugs that are water soluble with minimal protein binding (<80%) and low endogenous clearance and volume of distribution. The dosage of some antidotes ( e.g. , N-acetylcysteine, ethanol, fomepizole) should be increased to maintain therapeutic concentrations once the extracorporeal treatment is initiated. To maximize the effect of an extracorporeal treatment, blood and effluent flows should be optimized, the filter with the largest surface area selected, and duration tailored to remove enough poison to reduce toxicity. Intermittent hemodialysis is recommended in most cases when an extracorporeal treatment is required because it is the most efficient, and continuous kidney replacement therapy is prescribed in some circumstances, particularly if intermittent hemodialysis is not readily available.
中毒是在接触多种物质后发生的，包括药物，这些物质可导致严重的毒性，包括死亡。肾病医生可能参与导致肾脏疾病的中毒并进行针对性治疗。中毒患者的总体治疗方法包括初始急性复苏和进行风险评估，根据预期的严重程度以及患者的状况和可能需要的治疗来考虑暴露情况。在需要时，会给予时间关键的干预措施，例如胃肠道去污（例如，活性炭）和解毒剂。当需要增强消除技术时，通常会涉及肾病医生，例如尿液碱化或体外治疗。越来越多的数据可指导中毒患者使用体外治疗的决策。需要考虑的原则包括临床指征，例如是否存在、预期存在和/或持续存在严重毒性，以及体外治疗是否会显著去除毒物。对于低分子量、水溶性、蛋白结合率低（<80%）、内源性清除率和分布容积低的药物，体外清除率最高。一旦开始体外治疗，一些解毒剂（例如，N-乙酰半胱氨酸、乙醇、法莫替丁）的剂量应增加以维持治疗浓度。为了最大限度地提高体外治疗的效果，应优化血液和流出液流量，选择表面积最大的过滤器，并根据需要调整治疗时间以去除足够的毒物以降低毒性。大多数情况下，建议使用间歇性血液透析来进行体外治疗，因为这是最有效的方法，在某些情况下会规定连续肾脏替代治疗，特别是如果间歇性血液透析不易获得。
