N-Acetylcysteine and Hemodialysis in Severe Acetaminophen Toxicity in a 15-Year-Old Adolescent: A Case Report.

BACKGROUND Acetaminophen toxicity is a leading cause of liver injury in adolescents and is usually treated with N-acetylcysteine (NAC). Rarely, adjunctive therapies, including hemodialysis (HD) and fomepizole, are required. This report describes the case of a 15-year-old male adolescent who required 2 hemodialysis sessions greater than 24 hours apart after a massive, intentional ingestion of acetaminophen. CASE REPORT A 15-year-old male patient presented to care after a single, intentional ingestion of approximately 195 g of extended-release acetaminophen. He was started on NAC therapy, and due to concern for early mitochondrial failure, he underwent intermittent HD, with reduction of his acetaminophen level. However, over 24 hours later, his transaminases increased and liver synthetic function declined, and he underwent HD a second time. There was no evidence of bezoar formation on computed tomography (CT) scan, suggesting that ongoing absorption was due to the extended-release formulation consumed. After his second HD session, his laboratory values normalized and he was medically cleared for transfer to psychiatry. CONCLUSIONS The need for a second HD session in acetaminophen toxicity >24 hours after an initial successful HD session is unprecedented. Given an increasing market of extended-release products and the potential for co-ingestions with medications that slow gastrointestinal motility, HD may be more frequently employed going forward, potentially multiple times. While central lines should be removed promptly when no longer needed, we advise caution in removing dialysis catheters within 24 hours of initial HD in these patients, given the need to repeat HD in this case.