Metabolic acidosis with increased anion gap, oxaluria, and acute kidney injury: Answers
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CLINICAL QUIZ
Metabolic acidosis with increased anion gap, oxaluria, and acute kidney injury: Answers Bagdagul Aksu 1,2 & Erkin Rahimov 3,4 Sevinc Emre 2 & Aydan Sirin 2
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Alev Yilmaz 2,5
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Zeynep Yuruk Yildirim 2,5
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Ilmay Bilge 2,6
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Received: 2 August 2020 / Revised: 2 August 2020 / Accepted: 2 September 2020 # IPNA 2020
Keywords Acute kidney injury . Metabolic acidosis . Ethylene glycol intoxication
Answers
work several days prior, confirming our preliminary diagnosis of EG poisoning.
(1) What is the most likely cause of acute kidney injury? The patient in this case had somnolence, metabolic acidosis with increased anion gap, oxaluria, and steadily increasing serum creatinine. Based on laboratory findings, intoxication was initially suspected. Salicylate, barbiturate, methanol, and ethylene glycol (EG) poisoning were considered in differential diagnosis. The parents were questioned about the patient’s alcohol and drug history and psychological state (suicidal tendency) but no helpful information was obtained. The urine drug screen was negative, and a toxicology screen of the serum identified no heroin, cocaine, amphetamine or methamphetamine. Eventually, the patient’s friend called his father to report that the patient had recreationally drunk antifreeze at
This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04757-3 * Bagdagul Aksu [email protected] 1
Department of Pediatric Basic Sciences, Institute of Child Health, Istanbul University, 34390 Istanbul, Turkey
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Division of Pediatric Nephrology, Istanbul Faculty of Medicine, Istanbul University, 34390 Istanbul, Turkey
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Department of Child Health and Diseases, Istanbul Faculty of Medicine, Istanbul University, 34390 Istanbul, Turkey
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Department of Child Health and Diseases, Baku Medical Plaza, Baku, Azerbaijan
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Institute of Child Health, Istanbul University, 34390 Istanbul, Turkey
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Division of Pediatric Nephrology, Koc University Hospital, Istanbul, Turkey
(2) Which additional tests would you perform to confirm the diagnosis? Serum EG concentration can be checked to confirm the diagnosis. The patient’s serum EG level was above 200 mg/ L. The diagnosis and therapy guidelines for EG poisoning have been developed by the American Academy of Clinical Toxicology (Table 1) [1]. (3) How should this patient be treated? The initial approach in EG poisoning includes stabilization of the airway, breathing, circulation, and supportive therapy. The main goals in treating EG poisoning are prevention of toxic metabolite formation, infusion of bicarbonate for acidosis, use of specific enzymatic cofactors such as thiamine and pyridoxine, and removal of the toxins and metabolites by hemodialysis [2]. In our case, bicarbonate infusion was initiated to correct acidosis after the first evaluation. Serum creatinine steadily
Table 1
Criteria for antidotal therapy in ethylene glycol poisonings (1)
• Serum ethylene glycol concentration > 200 mg/L (3 mmol/L) or • Patient history of ingestion of a toxic dose of ethylene glyc
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