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    "textoCompleto" => "Poisoning induced by alcohols &#40;methanol&#44; ethanol&#44; or ethylene glycol&#41; may cause severe metabolic acidosis with high anion and&#47;or osmolal gaps&#44; neurological changes ranging from confusion to deep coma&#44; amaurosis&#44; and death&#46; Some patients may also develop acute renal failure&#46;1-3 Despite intensive treatment&#44; morbidity and mortality of these poisonings continue to be very high&#44; mainly because of the delay in diagnosis and start of treatment&#46;4&#44;5 If there is no history of methanol&#44; ethanol&#44; or ethylene glycol intake&#44; initial diagnosis is difficult&#46; Measurement of serum levels&#160; of&#160; toxic alcohol is helpful&#44; but is not always readily available on hospital admission&#46; Diagnosis is often based on an obvious epidemiological context&#44; and above all on the finding of metabolic acidosis with an elevated anion gap and&#47;or osmolal gap&#46;1-3 In some cases&#44; osmolal gap may overestimate the amount of alcohols&#160; present&#160; in&#160; serum&#44;6&#44;7 but a good linear correlation usually exists between them&#44; and in the absence of toxic alcohol levels&#44; osmolal gap allows for&#160; a quite approximate indirect estimation&#46;8&#44;9 Depending on the time elapsed since toxic exposure&#44; both biochemical changes may be present to a greater or lesser extent&#46; In the earliest phase of poisoning&#44; the osmolal gap is greater and the anion gap is lower&#44; while as the alcohol&#160; is&#160; metabolised&#160; the&#160; osmolal&#160; and&#160; anion&#160; gaps&#160; approximate&#160; to&#160; each&#160; other&#160; &#40;both&#160; being&#160; elevated&#41;&#44;&#160; and&#160; in&#160; the&#160; latest phase the osmolal gap tends to normalise and the anion gap continues to increase&#46;3&#44;8&#44;9 While less commonly&#44; poisoning by other alcohols such as diethylene glycol and propylene glycol may also cause metabolic acidosis with elevation of the anion and&#47;or osmolal gap&#44; whereas isopropanol only causes elevation of osmolality&#46;3 <br></br><br></br>Methanol&#160; poisoning may&#160; result&#160; from&#160; a&#160; suicidal&#160; attempt&#44; accidental intake&#44; or consumption instead of ethanol in chronic drinkers&#46; Methanol&#160; is&#160; a&#160; small molecule&#160; &#40;32 Da&#41;&#160; that&#160; is not bound to protein&#46; Its distribution volume is therefore relatively small &#40;0&#46;6-0&#46;7 L&#47;kg&#41;&#44; which allows for a particularly effective&#160; removal by haemodialysis&#160; &#40;HD&#41;&#46; Development of toxicity is related to plasma levels of methanol and its metabolites&#46;10 Its&#160; lethal&#160; dose&#160; is&#160; 50&#160; to&#160; 100&#160; mL&#44;&#160; but&#160; smaller amounts may induce permanent amaurosis1 and in some patients necrosis of basal ganglia&#44; more specifically&#160; the putamen&#44; or bleeding&#46;11-13 However&#44;&#160; there are&#160; reports of patients surviving with no organic damage to much higher methanol intakes&#46;11 Among subjects who experienced seizures&#44; coma&#44; or&#160; an&#160; initial&#160; pH&#160; &#60;&#160; 7&#44; mortality was&#160; higher&#160; than&#160; 80&#37;&#46;14 By contrast&#44; in the absence of these findings&#44; the mortality rate was&#160; less&#160; than&#160; 6&#37;&#46;&#160; In&#160; another&#160; series&#44;&#160; morbidity&#160; was&#160; also high&#44;&#160; and&#160; mortality&#160; occurred&#160; in&#160; up&#160; to&#160; 44&#37;&#160; and&#160; 48&#37;&#160; of <br></br>cases&#46;4&#44;5 The mortality rates in three large series recently reported were 18&#37;&#44; 19&#37;&#44; and 44&#37;&#160; respectively&#46; Methanol&#160; is metabolised&#160; by&#160; the&#160; enzyme&#160; alcohol&#160; dehydrogenase&#160; &#40;ADH&#41; to yield&#160; formic acid&#44;&#160; responsible&#160; for metabolic acidosis&#46;18&#44;19 Management&#160; of&#160; severe methanol&#160; poisoning&#160; includes&#160; administration of ethanol or fomepizole and early start of HD&#46;11&#44;20&#44;22 Indications&#160; for&#160; ethanol&#160; administration&#160; include&#160; methanol levels &#62; 20 mg&#47;dL or&#160; an osmolal gap &#62; 10 mosm&#47;L in&#160; the event of recent intake or when poisoning is strongly suspected&#46; General indications of HD include high serum methanol levels&#160; &#40;&#62;&#160; 50&#160; mg&#47;dL&#41;&#44;&#160; metabolic&#160; acidosis&#44;&#160; and&#160; visual&#160; and mental&#160; changes&#46;3 In&#160; addition&#44;&#160; in methanol&#160; poisoning&#160; folic acid&#160; is&#160; effective&#160; for&#160; accelerating&#160; formate metabolism&#160; into carbon dioxide and water&#46;11&#44;22 <br></br><br></br>Ethylene&#160; glycol&#160; is&#160; a&#160; component&#160; of&#160; antifreezes&#160; and&#160; solvents&#46; Poisoning is usually due to accidental intake&#46; Ethylene glycol&#160; is a small molecule&#160; &#40;62 Da&#41;&#160; that&#160; is not bound&#160; to protein&#160; and&#160; has&#160; a&#160; distribution&#160; volume&#160; of&#160; 0&#46;5-0&#46;8 L&#47;kg&#46;&#160; Its lethal dose&#160; is approximately 100 mL&#46; Earliest&#160; findings&#160; include neurological changes ranging from confusion to deep coma&#46; If untreated&#44; these findings may be followed by cardiopulmonary symptoms &#40;tachypnoea and pulmonary oedema&#41; and acute renal failure&#44; that may be associated to marked&#160; crystalluria&#160; in&#160; urinary&#160; sediment&#160; &#40;oxalate&#160; crystals&#41;&#46;23 Acid-base changes and clinical symptoms are due to accumulation&#160; of&#160; toxic metabolites&#44;&#160; rather&#160; than&#160; to&#160; the&#160; original toxic compound&#46;1-3 Ethylene glycol is metabolised by ADH to&#160; a&#160; variety&#160; of&#160; toxic&#160; compounds&#160; including&#160; glycolic&#160; acid &#40;that may be&#160; toxic&#160; for&#160; renal&#160; tubules&#41;&#160; and oxalic&#160; acid&#160; &#40;that may&#160; precipitate&#160; in&#160; the&#160; tubules&#41;&#46;23&#44;24 The&#160; mortality&#160; rate&#160; of ethylene&#160; glycol&#160; poisoning&#160; is&#160; variable&#44;&#160; ranging&#160; from&#160; 1&#37;-22&#37;&#46;25 The highest mortality is found in patients with most severe&#160; metabolic&#160; acidosis&#160; and&#160; longer&#160; delay&#160; in&#160; treatment start&#46; Management of severe ethylene glycol poisoning&#160; includes&#160; administration&#160; of&#160; ethanol&#160; or&#160; fomepizole&#160; and&#160; early start of HD&#46;3&#44;24&#44;26&#44;27 General&#160; indications&#160; for HD&#160; include high ethylene glycol plasma levels &#40;over 20 mg&#47;dL&#41;&#44; severe metabolic&#160; acidosis&#160; and&#47;or&#160; an&#160; osmolal&#160; gap&#160; also&#160; elevated&#46;&#160; In ethylene glycol poisoning&#44; vitamins thiamine and pyridoxine may&#160; be&#160; effective&#160; for&#160; promoting&#160; conversion&#160; of&#160; glycolic acid into&#160; -hydroxy- -ketoadipate and glyoxylate into metabolites less toxic than oxalate&#44; such as glycine&#46;27&#44;28 Moreover&#44; during ethylene glycol poisoning&#44;&#160; forced diuresis may preserve&#160; kidney&#160; function&#160; by minimising&#160; tubular&#160; blockade <br></br>by oxalate crystals&#46; <br></br><br></br>Ethanol has a molecular weight of 46 Da and a distribution&#160; volume&#160; of&#160; 0&#46;5&#160; L&#47;kg&#46;1-3 Ethanol&#160; exerts&#160; its&#160; actions&#160; through several mechanisms&#46; Thus&#44; it is directly bound to the gamma-aminobutyric&#160; acid&#160; &#40;GABA&#41;&#160; receptor&#160; in&#160; the&#160; CNS and&#160; causes&#160; sedative&#160; effects&#160; similar&#160; to&#160; benzodiazepines&#44; which&#160; bind&#160; to&#160; the&#160; same&#160; GABA receptor&#46;&#160; Ethanol&#160; levels peak&#160; 30-60 min&#160; after&#160; intake&#46;&#160; Ethanol&#160; absorption&#160; starts&#160; at the oral mucosa&#160; and&#160; continues&#160; in&#160; the&#160; stomach&#160; and bowel&#46; Ethanol&#160; is mainly metabolised&#160; in&#160; the&#160; liver&#46; Approximately 90&#37; of an ethanol overload is metabolized in the liver&#44; and the remaining 10&#37; is eliminated by the kidneys and lungs&#46; In the liver&#44; ethanol is converted by the action of ADH into acetaldehyde&#44; which&#160; is&#160; then metabolised&#160; to&#160; acetic&#160; acid by acetaldehyde dehydrogenase&#46; Acetic acid enters&#160; the Krebs cycle&#160; and&#160; is&#160; finally&#160; converted&#160; into&#160; carbon&#160; dioxide&#160; and water&#46;&#160; Clinical&#160; findings with&#160; different&#160; ethanol&#160; concentrations&#160; may&#160; be&#160; classified&#160; as&#160; follows&#58;&#160; poisoning&#160; 100-150 mg&#47;dL&#44; loss of muscle coordination 150-200 mg&#47;dL&#44; decreased&#160; level&#160; of&#160; consciousness&#160; 200-300&#160; mg&#47;dL&#44;&#160; and&#160; death 300-500&#160; mg&#47;dL&#46; Alcoholic&#160; ketoacidosis&#160; syndrome&#160; is&#160; uncommon and usually occurs&#160; in patients with chronic ethanol ingestion and hepatic disease&#46;29-32 The syndrome occurs during periods of high ethanol intake and low food intake&#46; It&#160; is&#160; therefore&#160; common&#160; to&#160; find metabolic&#160; acidosis with&#160; a high anion gap and sometimes with an also elevated osmolal gap&#46; HD is able to efficiently clear ethanol from blood&#44; but&#160; should not be&#160; routinely used because&#160; it&#160; is an&#160; invasive procedure&#46; In addition&#44; HD has only been used in some isolated&#160; cases&#160; of&#160; acute&#160; ethanol&#160; intoxication&#160; in&#160; pregnant women&#46; <br></br><br></br>Alcohol&#160; absorption&#160; from&#160; the&#160; gastrointestinal&#160; tract&#160; is rapid&#46; Thus&#44;&#160; gastric&#160; lavage&#44;&#160; vomiting&#160; induction&#44;&#160; or&#160; use&#160; of activated charcoal should be started in 30-60 minutes to be beneficial&#46; Treatment of metabolic acidosis with bicarbonate&#160; is a priority&#160; that also allows&#160; for&#160; increasing&#160; renal excretion&#160; of&#160; formic&#160; cid&#160; and&#160; glycolate&#46;15&#44;33-35 Bicarbonate may&#160; be administered by&#160; the&#160; intravenous&#160; route or HD&#46; Administration of ethanol or fomepizole to delay metabolism of alcohols&#44; methanol&#160; and&#160; ethylene&#160; glycol&#44;&#160; is&#160; an&#160; integral&#160; part&#160; of therapy&#46; Though it has never been approved by the FDA&#44; ethanol has been used for the treatment of poisoning by methanol&#160; and&#160; ethylene&#160; glycol&#160; for&#160; many&#160; years&#46;11&#44;20&#44;28&#44;36 Ethanol has a 10 to 20-fold greater affinity for ADH as compared to <br></br>other&#160; alcohols&#44;&#160; and&#160; completely&#160; inhibits ADH&#160; at&#160; a&#160; serum concentration of 100 mg&#47;dL&#46;3 Fomepizole &#40;4-methylpyrazole&#44; Antizol&#59;&#160; Jazz&#160; Pharmaceuticals&#44;&#160; Palo Alto&#44; CA&#41;&#160; has&#160; approximately a 500 to 1&#44;000-fold greater affinity for ADH as compared&#160; to ethanol and may completely&#160; inhibit&#160; the enzyme&#160; at&#160; a&#160; much&#160; lower&#160; serum&#160; concentration&#46;11&#44;37 Fomepizole has a distribution volume of 0&#46;6 to 1 L&#47;kg and a low protein biding&#44;&#160; and&#160; is&#160; eliminated&#160; by metabolism&#160; in&#160; the&#160; liver&#160; and renal&#160; excretion&#46; Studies&#160; in&#160; humans&#160; have&#160; confirmed&#160; its&#160; effectiveness&#160; for&#160; preventing&#160; metabolism&#160; of&#160; methanol&#160; and ethylene glycol to its toxic products&#46; Fomepizole is therefore approved by the US FDA for the treatment of both poisonings&#46; Fomepizole&#160; is&#160; removed by HD&#44; and&#160; its dose should therefore&#160; be&#160; increased&#160; during&#160; the&#160; dialysis&#160; procedure&#46; The problems&#160; for&#160; use&#160; of&#160; fomepizole&#160; are&#160; its&#160; unavailability&#160; in many&#160; countries&#160; and&#160; its high price&#160; &#40;approximately 7800 e per treatment&#41;&#46;15 In addition&#44; a recent study conducted on 20 patients&#160; treated with&#160; fomepizole&#160; and&#47;or&#160; ethanol&#160; could&#160; not elucidate&#160; in practice&#160; the&#160; superiority of one over&#160; the other&#44; and controversy therefore continues&#46;37 <br></br><br></br>Ethanol is dialysable&#44; and when HD is required the dose of ethanol to be administered should be adjusted&#46; Reduction <br></br>in&#160; ethanol&#160; levels&#160; during HD may&#160; be&#160; prevented&#160; by&#160; increasing infusion rate or by adding ethanol directly to the dialysis bath&#46;10&#44;38&#44;39 Efficacy of ethanol administration&#160; for&#160; inhibiting ADH&#160; is&#160; higher when&#160; plasma&#160; ethanol&#160; levels&#160; are&#160; from 100&#160; to 200 mg&#47;dL&#46; These&#160; levels may be&#160; reached by administering ethanol IV at the following dosage regimen&#58; a loading dose of 0&#46;6 g&#47;kg body weight&#44; plus an hourly maintenance&#160; dose&#160; of&#160; 66&#160; mg&#47;kg&#160; in&#160; non-drinkers&#44;&#160; 154&#160; mg&#47;kg&#160; in drinkers&#44; and 240 mg&#47;kg when HD is started&#46;3 Regardless of how ethanol&#160; is administered&#44; ethanol plasma&#160; levels should be&#160; monitored&#160; whenever&#160; possible&#44;&#160; because&#160; many&#160; patients will&#160; require&#160; dose&#160; adjustments&#46;&#160; Ethanol&#160; infusion&#160; and&#160; HD should be continued until&#160; the serum&#160; levels of&#160; the&#160; toxic are <br></br>sufficiently low or have completely disappeared&#46; When poisoning by these toxic alcohols is clinically suspected&#44; even <br></br>before pharmacological confirmation is obtained&#44; treatment with ethanol and HD should be started as soon as possible&#46; Conventional&#160; HD&#160; may&#160; rapidly&#160; decrease&#160; plasma&#160; levels&#160; of these alcohols&#44; and also of their toxic metabolites&#44; simultaneously&#160; correcting&#160; electrolyte&#160; and&#160; acid-base&#160; disorders&#46; Continuous&#160; procedures&#160; have&#160; been&#160; used&#160; in&#160; some&#160; isolated cases&#44;40 but results superior to those reported with HD have not been shown to date&#46; <br></br><br></br>Randomised&#44; controlled studies would be useful to provide evidence-based guidelines for the treatment of the different&#160; phases&#160; of&#160; alcohol-induced&#160; poisoning&#46; While&#160; no&#160; such controlled&#160; studies&#160; allowing&#160; for&#160; assessing&#160; the&#160; value&#160; of&#160; the different therapies are available&#44; the study published in this issue&#160; of NEFROLOGIA41 demonstrates&#160; that&#160; early&#160; start&#160; of HD&#160; techniques&#160; using&#160; a&#160; bicarbonate&#160; bath&#160; enriched&#160; with phosphorus&#160; and&#160; potassium39&#44;41&#44;42 and&#160; high&#160; efficiency&#160; dialysers&#160; achieves&#160; an&#160; excellent&#160; removal&#160; of&#160; methanol&#44;&#160; ethanol&#44; and ethylene glycol&#44; as well as their toxic metabolites&#44; producing&#160; at&#160; the&#160; same&#160; time&#160; a&#160; rapid&#160; correction of water&#44;&#160; electrolyte&#44; and acid-base disturbances&#46; Measures implemented in&#160; this&#160; study&#160; represent&#160; a&#160; combination&#160; of&#160; relatively&#160; simple <br></br>and safe procedures&#160; that decrease morbidity and mortality&#44; allowing&#160; for&#160; a&#160; shorter&#160; hospital&#160; stay&#46;&#160; However&#44;&#160; our&#160; study was&#160; limited&#160; by&#160; its&#160; relatively&#160; small&#160; number&#160; of&#160; patients&#44; though&#160; this was&#160; the&#160; largest&#160; series&#160; &#40;of&#160; cases&#160; from&#160; a&#160; single centre&#41;&#160; reported&#160; to date&#160; in Spain&#46; Taking&#160; into account&#160; that there&#160; has&#160; been&#160; in&#160; recent&#160; years&#160; in&#160; the Madrid Autonomous Community an increase in the number of cases of methanol poisoning among&#160; immigrants who massively drank methanol during social events and who were referred to different hospitals&#44; it would be appropriate for centres to coordinate their action protocols&#44; and to share databases in order to be able to conduct cooperative studies&#46; <br></br>"
    "pdfFichero" => "P-E-S-A381-EN.pdf"
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    "resumen" => array:2 [
      "es" => array:1 [
        "resumen" => "La intoxicaci&#243;n por alcoholes &#40;metanol&#44; etanol o etilenglicol&#41; puede originar acidosis metab&#243;lica severa con hiato ani&#243;nico y&#47;o osmolal elevados&#44; alteraciones neurol&#243;gicas que van desde la obnubilaci&#243;n al coma profundo&#44; amaurosis&#44; y muerte&#46; Adem&#225;s&#44; algunos pacientes pueden desarrollar un cuadro de fracaso renal agudo &#91;1-3&#93;&#46; A pesar de la terapia intensiva la morbilidad y la mortalidad de estas intoxicaciones siguen siendo muy elevadas&#44; debido fundamentalmente al retraso en el diagn&#243;stico y en el inicio del tratamiento &#91;4&#44; 5&#93;&#46; En ausencia de una historia de ingesta de metanol&#44; etanol o etilenglicol&#44; el diagn&#243;stico inicial es dif&#237;cil de realizar&#46; La determinaci&#243;n de los niveles s&#233;ricos del alcohol t&#243;xico es &#250;til&#44; pero no siempre se encuentran disponibles inmediatamente al ingreso en el hospital&#46;"
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        "resumen" => "Poisoning induced by alcohols &#40;methanol&#44; ethanol&#44; or ethylene glycol&#41; may cause severe metabolic acidosis with high anion and&#47;or osmolal gaps&#44; neurological changes ranging from confusion to deep coma&#44; amaurosis&#44; and death&#46; Some patients may also develop acute renal failure&#46;1-3 Despite intensive treatment&#44; morbidity and mortality of these poisonings continue to be very high&#44; mainly because of the delay in diagnosis and start of treatment&#46;"
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Treatment of severe alcohol poisoning
Tratamiento de las intoxicaciones graves por alcoholes
R.. Pecesa, E.. Gonzáleza, R.. Selgasa, C.. Pecesb
a Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Madrid, España,
b 2Área de Tecnología de la Información, SESCAM, Toledo, Toledo, España,
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    "textoCompleto" => "Poisoning induced by alcohols &#40;methanol&#44; ethanol&#44; or ethylene glycol&#41; may cause severe metabolic acidosis with high anion and&#47;or osmolal gaps&#44; neurological changes ranging from confusion to deep coma&#44; amaurosis&#44; and death&#46; Some patients may also develop acute renal failure&#46;1-3 Despite intensive treatment&#44; morbidity and mortality of these poisonings continue to be very high&#44; mainly because of the delay in diagnosis and start of treatment&#46;4&#44;5 If there is no history of methanol&#44; ethanol&#44; or ethylene glycol intake&#44; initial diagnosis is difficult&#46; Measurement of serum levels&#160; of&#160; toxic alcohol is helpful&#44; but is not always readily available on hospital admission&#46; Diagnosis is often based on an obvious epidemiological context&#44; and above all on the finding of metabolic acidosis with an elevated anion gap and&#47;or osmolal gap&#46;1-3 In some cases&#44; osmolal gap may overestimate the amount of alcohols&#160; present&#160; in&#160; serum&#44;6&#44;7 but a good linear correlation usually exists between them&#44; and in the absence of toxic alcohol levels&#44; osmolal gap allows for&#160; a quite approximate indirect estimation&#46;8&#44;9 Depending on the time elapsed since toxic exposure&#44; both biochemical changes may be present to a greater or lesser extent&#46; In the earliest phase of poisoning&#44; the osmolal gap is greater and the anion gap is lower&#44; while as the alcohol&#160; is&#160; metabolised&#160; the&#160; osmolal&#160; and&#160; anion&#160; gaps&#160; approximate&#160; to&#160; each&#160; other&#160; &#40;both&#160; being&#160; elevated&#41;&#44;&#160; and&#160; in&#160; the&#160; latest phase the osmolal gap tends to normalise and the anion gap continues to increase&#46;3&#44;8&#44;9 While less commonly&#44; poisoning by other alcohols such as diethylene glycol and propylene glycol may also cause metabolic acidosis with elevation of the anion and&#47;or osmolal gap&#44; whereas isopropanol only causes elevation of osmolality&#46;3 <br></br><br></br>Methanol&#160; poisoning may&#160; result&#160; from&#160; a&#160; suicidal&#160; attempt&#44; accidental intake&#44; or consumption instead of ethanol in chronic drinkers&#46; Methanol&#160; is&#160; a&#160; small molecule&#160; &#40;32 Da&#41;&#160; that&#160; is not bound to protein&#46; Its distribution volume is therefore relatively small &#40;0&#46;6-0&#46;7 L&#47;kg&#41;&#44; which allows for a particularly effective&#160; removal by haemodialysis&#160; &#40;HD&#41;&#46; Development of toxicity is related to plasma levels of methanol and its metabolites&#46;10 Its&#160; lethal&#160; dose&#160; is&#160; 50&#160; to&#160; 100&#160; mL&#44;&#160; but&#160; smaller amounts may induce permanent amaurosis1 and in some patients necrosis of basal ganglia&#44; more specifically&#160; the putamen&#44; or bleeding&#46;11-13 However&#44;&#160; there are&#160; reports of patients surviving with no organic damage to much higher methanol intakes&#46;11 Among subjects who experienced seizures&#44; coma&#44; or&#160; an&#160; initial&#160; pH&#160; &#60;&#160; 7&#44; mortality was&#160; higher&#160; than&#160; 80&#37;&#46;14 By contrast&#44; in the absence of these findings&#44; the mortality rate was&#160; less&#160; than&#160; 6&#37;&#46;&#160; In&#160; another&#160; series&#44;&#160; morbidity&#160; was&#160; also high&#44;&#160; and&#160; mortality&#160; occurred&#160; in&#160; up&#160; to&#160; 44&#37;&#160; and&#160; 48&#37;&#160; of <br></br>cases&#46;4&#44;5 The mortality rates in three large series recently reported were 18&#37;&#44; 19&#37;&#44; and 44&#37;&#160; respectively&#46; Methanol&#160; is metabolised&#160; by&#160; the&#160; enzyme&#160; alcohol&#160; dehydrogenase&#160; &#40;ADH&#41; to yield&#160; formic acid&#44;&#160; responsible&#160; for metabolic acidosis&#46;18&#44;19 Management&#160; of&#160; severe methanol&#160; poisoning&#160; includes&#160; administration of ethanol or fomepizole and early start of HD&#46;11&#44;20&#44;22 Indications&#160; for&#160; ethanol&#160; administration&#160; include&#160; methanol levels &#62; 20 mg&#47;dL or&#160; an osmolal gap &#62; 10 mosm&#47;L in&#160; the event of recent intake or when poisoning is strongly suspected&#46; General indications of HD include high serum methanol levels&#160; &#40;&#62;&#160; 50&#160; mg&#47;dL&#41;&#44;&#160; metabolic&#160; acidosis&#44;&#160; and&#160; visual&#160; and mental&#160; changes&#46;3 In&#160; addition&#44;&#160; in methanol&#160; poisoning&#160; folic acid&#160; is&#160; effective&#160; for&#160; accelerating&#160; formate metabolism&#160; into carbon dioxide and water&#46;11&#44;22 <br></br><br></br>Ethylene&#160; glycol&#160; is&#160; a&#160; component&#160; of&#160; antifreezes&#160; and&#160; solvents&#46; Poisoning is usually due to accidental intake&#46; Ethylene glycol&#160; is a small molecule&#160; &#40;62 Da&#41;&#160; that&#160; is not bound&#160; to protein&#160; and&#160; has&#160; a&#160; distribution&#160; volume&#160; of&#160; 0&#46;5-0&#46;8 L&#47;kg&#46;&#160; Its lethal dose&#160; is approximately 100 mL&#46; Earliest&#160; findings&#160; include neurological changes ranging from confusion to deep coma&#46; If untreated&#44; these findings may be followed by cardiopulmonary symptoms &#40;tachypnoea and pulmonary oedema&#41; and acute renal failure&#44; that may be associated to marked&#160; crystalluria&#160; in&#160; urinary&#160; sediment&#160; &#40;oxalate&#160; crystals&#41;&#46;23 Acid-base changes and clinical symptoms are due to accumulation&#160; of&#160; toxic metabolites&#44;&#160; rather&#160; than&#160; to&#160; the&#160; original toxic compound&#46;1-3 Ethylene glycol is metabolised by ADH to&#160; a&#160; variety&#160; of&#160; toxic&#160; compounds&#160; including&#160; glycolic&#160; acid &#40;that may be&#160; toxic&#160; for&#160; renal&#160; tubules&#41;&#160; and oxalic&#160; acid&#160; &#40;that may&#160; precipitate&#160; in&#160; the&#160; tubules&#41;&#46;23&#44;24 The&#160; mortality&#160; rate&#160; of ethylene&#160; glycol&#160; poisoning&#160; is&#160; variable&#44;&#160; ranging&#160; from&#160; 1&#37;-22&#37;&#46;25 The highest mortality is found in patients with most severe&#160; metabolic&#160; acidosis&#160; and&#160; longer&#160; delay&#160; in&#160; treatment start&#46; Management of severe ethylene glycol poisoning&#160; includes&#160; administration&#160; of&#160; ethanol&#160; or&#160; fomepizole&#160; and&#160; early start of HD&#46;3&#44;24&#44;26&#44;27 General&#160; indications&#160; for HD&#160; include high ethylene glycol plasma levels &#40;over 20 mg&#47;dL&#41;&#44; severe metabolic&#160; acidosis&#160; and&#47;or&#160; an&#160; osmolal&#160; gap&#160; also&#160; elevated&#46;&#160; In ethylene glycol poisoning&#44; vitamins thiamine and pyridoxine may&#160; be&#160; effective&#160; for&#160; promoting&#160; conversion&#160; of&#160; glycolic acid into&#160; -hydroxy- -ketoadipate and glyoxylate into metabolites less toxic than oxalate&#44; such as glycine&#46;27&#44;28 Moreover&#44; during ethylene glycol poisoning&#44;&#160; forced diuresis may preserve&#160; kidney&#160; function&#160; by minimising&#160; tubular&#160; blockade <br></br>by oxalate crystals&#46; <br></br><br></br>Ethanol has a molecular weight of 46 Da and a distribution&#160; volume&#160; of&#160; 0&#46;5&#160; L&#47;kg&#46;1-3 Ethanol&#160; exerts&#160; its&#160; actions&#160; through several mechanisms&#46; Thus&#44; it is directly bound to the gamma-aminobutyric&#160; acid&#160; &#40;GABA&#41;&#160; receptor&#160; in&#160; the&#160; CNS and&#160; causes&#160; sedative&#160; effects&#160; similar&#160; to&#160; benzodiazepines&#44; which&#160; bind&#160; to&#160; the&#160; same&#160; GABA receptor&#46;&#160; Ethanol&#160; levels peak&#160; 30-60 min&#160; after&#160; intake&#46;&#160; Ethanol&#160; absorption&#160; starts&#160; at the oral mucosa&#160; and&#160; continues&#160; in&#160; the&#160; stomach&#160; and bowel&#46; Ethanol&#160; is mainly metabolised&#160; in&#160; the&#160; liver&#46; Approximately 90&#37; of an ethanol overload is metabolized in the liver&#44; and the remaining 10&#37; is eliminated by the kidneys and lungs&#46; In the liver&#44; ethanol is converted by the action of ADH into acetaldehyde&#44; which&#160; is&#160; then metabolised&#160; to&#160; acetic&#160; acid by acetaldehyde dehydrogenase&#46; Acetic acid enters&#160; the Krebs cycle&#160; and&#160; is&#160; finally&#160; converted&#160; into&#160; carbon&#160; dioxide&#160; and water&#46;&#160; Clinical&#160; findings with&#160; different&#160; ethanol&#160; concentrations&#160; may&#160; be&#160; classified&#160; as&#160; follows&#58;&#160; poisoning&#160; 100-150 mg&#47;dL&#44; loss of muscle coordination 150-200 mg&#47;dL&#44; decreased&#160; level&#160; of&#160; consciousness&#160; 200-300&#160; mg&#47;dL&#44;&#160; and&#160; death 300-500&#160; mg&#47;dL&#46; Alcoholic&#160; ketoacidosis&#160; syndrome&#160; is&#160; uncommon and usually occurs&#160; in patients with chronic ethanol ingestion and hepatic disease&#46;29-32 The syndrome occurs during periods of high ethanol intake and low food intake&#46; It&#160; is&#160; therefore&#160; common&#160; to&#160; find metabolic&#160; acidosis with&#160; a high anion gap and sometimes with an also elevated osmolal gap&#46; HD is able to efficiently clear ethanol from blood&#44; but&#160; should not be&#160; routinely used because&#160; it&#160; is an&#160; invasive procedure&#46; In addition&#44; HD has only been used in some isolated&#160; cases&#160; of&#160; acute&#160; ethanol&#160; intoxication&#160; in&#160; pregnant women&#46; <br></br><br></br>Alcohol&#160; absorption&#160; from&#160; the&#160; gastrointestinal&#160; tract&#160; is rapid&#46; Thus&#44;&#160; gastric&#160; lavage&#44;&#160; vomiting&#160; induction&#44;&#160; or&#160; use&#160; of activated charcoal should be started in 30-60 minutes to be beneficial&#46; Treatment of metabolic acidosis with bicarbonate&#160; is a priority&#160; that also allows&#160; for&#160; increasing&#160; renal excretion&#160; of&#160; formic&#160; cid&#160; and&#160; glycolate&#46;15&#44;33-35 Bicarbonate may&#160; be administered by&#160; the&#160; intravenous&#160; route or HD&#46; Administration of ethanol or fomepizole to delay metabolism of alcohols&#44; methanol&#160; and&#160; ethylene&#160; glycol&#44;&#160; is&#160; an&#160; integral&#160; part&#160; of therapy&#46; Though it has never been approved by the FDA&#44; ethanol has been used for the treatment of poisoning by methanol&#160; and&#160; ethylene&#160; glycol&#160; for&#160; many&#160; years&#46;11&#44;20&#44;28&#44;36 Ethanol has a 10 to 20-fold greater affinity for ADH as compared to <br></br>other&#160; alcohols&#44;&#160; and&#160; completely&#160; inhibits ADH&#160; at&#160; a&#160; serum concentration of 100 mg&#47;dL&#46;3 Fomepizole &#40;4-methylpyrazole&#44; Antizol&#59;&#160; Jazz&#160; Pharmaceuticals&#44;&#160; Palo Alto&#44; CA&#41;&#160; has&#160; approximately a 500 to 1&#44;000-fold greater affinity for ADH as compared&#160; to ethanol and may completely&#160; inhibit&#160; the enzyme&#160; at&#160; a&#160; much&#160; lower&#160; serum&#160; concentration&#46;11&#44;37 Fomepizole has a distribution volume of 0&#46;6 to 1 L&#47;kg and a low protein biding&#44;&#160; and&#160; is&#160; eliminated&#160; by metabolism&#160; in&#160; the&#160; liver&#160; and renal&#160; excretion&#46; Studies&#160; in&#160; humans&#160; have&#160; confirmed&#160; its&#160; effectiveness&#160; for&#160; preventing&#160; metabolism&#160; of&#160; methanol&#160; and ethylene glycol to its toxic products&#46; Fomepizole is therefore approved by the US FDA for the treatment of both poisonings&#46; Fomepizole&#160; is&#160; removed by HD&#44; and&#160; its dose should therefore&#160; be&#160; increased&#160; during&#160; the&#160; dialysis&#160; procedure&#46; The problems&#160; for&#160; use&#160; of&#160; fomepizole&#160; are&#160; its&#160; unavailability&#160; in many&#160; countries&#160; and&#160; its high price&#160; &#40;approximately 7800 e per treatment&#41;&#46;15 In addition&#44; a recent study conducted on 20 patients&#160; treated with&#160; fomepizole&#160; and&#47;or&#160; ethanol&#160; could&#160; not elucidate&#160; in practice&#160; the&#160; superiority of one over&#160; the other&#44; and controversy therefore continues&#46;37 <br></br><br></br>Ethanol is dialysable&#44; and when HD is required the dose of ethanol to be administered should be adjusted&#46; Reduction <br></br>in&#160; ethanol&#160; levels&#160; during HD may&#160; be&#160; prevented&#160; by&#160; increasing infusion rate or by adding ethanol directly to the dialysis bath&#46;10&#44;38&#44;39 Efficacy of ethanol administration&#160; for&#160; inhibiting ADH&#160; is&#160; higher when&#160; plasma&#160; ethanol&#160; levels&#160; are&#160; from 100&#160; to 200 mg&#47;dL&#46; These&#160; levels may be&#160; reached by administering ethanol IV at the following dosage regimen&#58; a loading dose of 0&#46;6 g&#47;kg body weight&#44; plus an hourly maintenance&#160; dose&#160; of&#160; 66&#160; mg&#47;kg&#160; in&#160; non-drinkers&#44;&#160; 154&#160; mg&#47;kg&#160; in drinkers&#44; and 240 mg&#47;kg when HD is started&#46;3 Regardless of how ethanol&#160; is administered&#44; ethanol plasma&#160; levels should be&#160; monitored&#160; whenever&#160; possible&#44;&#160; because&#160; many&#160; patients will&#160; require&#160; dose&#160; adjustments&#46;&#160; Ethanol&#160; infusion&#160; and&#160; HD should be continued until&#160; the serum&#160; levels of&#160; the&#160; toxic are <br></br>sufficiently low or have completely disappeared&#46; When poisoning by these toxic alcohols is clinically suspected&#44; even <br></br>before pharmacological confirmation is obtained&#44; treatment with ethanol and HD should be started as soon as possible&#46; Conventional&#160; HD&#160; may&#160; rapidly&#160; decrease&#160; plasma&#160; levels&#160; of these alcohols&#44; and also of their toxic metabolites&#44; simultaneously&#160; correcting&#160; electrolyte&#160; and&#160; acid-base&#160; disorders&#46; Continuous&#160; procedures&#160; have&#160; been&#160; used&#160; in&#160; some&#160; isolated cases&#44;40 but results superior to those reported with HD have not been shown to date&#46; <br></br><br></br>Randomised&#44; controlled studies would be useful to provide evidence-based guidelines for the treatment of the different&#160; phases&#160; of&#160; alcohol-induced&#160; poisoning&#46; While&#160; no&#160; such controlled&#160; studies&#160; allowing&#160; for&#160; assessing&#160; the&#160; value&#160; of&#160; the different therapies are available&#44; the study published in this issue&#160; of NEFROLOGIA41 demonstrates&#160; that&#160; early&#160; start&#160; of HD&#160; techniques&#160; using&#160; a&#160; bicarbonate&#160; bath&#160; enriched&#160; with phosphorus&#160; and&#160; potassium39&#44;41&#44;42 and&#160; high&#160; efficiency&#160; dialysers&#160; achieves&#160; an&#160; excellent&#160; removal&#160; of&#160; methanol&#44;&#160; ethanol&#44; and ethylene glycol&#44; as well as their toxic metabolites&#44; producing&#160; at&#160; the&#160; same&#160; time&#160; a&#160; rapid&#160; correction of water&#44;&#160; electrolyte&#44; and acid-base disturbances&#46; Measures implemented in&#160; this&#160; study&#160; represent&#160; a&#160; combination&#160; of&#160; relatively&#160; simple <br></br>and safe procedures&#160; that decrease morbidity and mortality&#44; allowing&#160; for&#160; a&#160; shorter&#160; hospital&#160; stay&#46;&#160; However&#44;&#160; our&#160; study was&#160; limited&#160; by&#160; its&#160; relatively&#160; small&#160; number&#160; of&#160; patients&#44; though&#160; this was&#160; the&#160; largest&#160; series&#160; &#40;of&#160; cases&#160; from&#160; a&#160; single centre&#41;&#160; reported&#160; to date&#160; in Spain&#46; Taking&#160; into account&#160; that there&#160; has&#160; been&#160; in&#160; recent&#160; years&#160; in&#160; the Madrid Autonomous Community an increase in the number of cases of methanol poisoning among&#160; immigrants who massively drank methanol during social events and who were referred to different hospitals&#44; it would be appropriate for centres to coordinate their action protocols&#44; and to share databases in order to be able to conduct cooperative studies&#46; <br></br>"
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        "resumen" => "La intoxicaci&#243;n por alcoholes &#40;metanol&#44; etanol o etilenglicol&#41; puede originar acidosis metab&#243;lica severa con hiato ani&#243;nico y&#47;o osmolal elevados&#44; alteraciones neurol&#243;gicas que van desde la obnubilaci&#243;n al coma profundo&#44; amaurosis&#44; y muerte&#46; Adem&#225;s&#44; algunos pacientes pueden desarrollar un cuadro de fracaso renal agudo &#91;1-3&#93;&#46; A pesar de la terapia intensiva la morbilidad y la mortalidad de estas intoxicaciones siguen siendo muy elevadas&#44; debido fundamentalmente al retraso en el diagn&#243;stico y en el inicio del tratamiento &#91;4&#44; 5&#93;&#46; En ausencia de una historia de ingesta de metanol&#44; etanol o etilenglicol&#44; el diagn&#243;stico inicial es dif&#237;cil de realizar&#46; La determinaci&#243;n de los niveles s&#233;ricos del alcohol t&#243;xico es &#250;til&#44; pero no siempre se encuentran disponibles inmediatamente al ingreso en el hospital&#46;"
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        "resumen" => "Poisoning induced by alcohols &#40;methanol&#44; ethanol&#44; or ethylene glycol&#41; may cause severe metabolic acidosis with high anion and&#47;or osmolal gaps&#44; neurological changes ranging from confusion to deep coma&#44; amaurosis&#44; and death&#46; Some patients may also develop acute renal failure&#46;1-3 Despite intensive treatment&#44; morbidity and mortality of these poisonings continue to be very high&#44; mainly because of the delay in diagnosis and start of treatment&#46;"
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                  "referenciaCompleta" => "Sivilotti ML, Winchester JF. Methanol and ethylene glycol intoxication. Version 15.3. UpToDate Inc. Wellesley, USA, 2008."
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ISSN: 20132514
Original language: English
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