Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

EXTRIP workgroup · 2023 · international

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Authors: Marc Ghannoum, Sophie Gosselin, Robert S Hoffman et al.
Title: Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup
Journal: Critical Care, 2023
DOI: 10.1186/s13054-022-04227-2
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC9921105

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Dialyzability of EG

As mentioned, once ADH is blocked by ethanol or fomepizole, endogenous EG clearance is at best 30 mL/min, which is modest relative to extracorporeal EG clearances with modern-day efficient ECTRs (Table 2) [148, 192, 209, 211]. For this reason, dialyzability was not graded based on kidney function. Although most of the toxicokinetic data are dated with technology considered substandard today, EG was considered “dialyzable” with intermittent hemodialysis (level of evidence = B, Table 3), “moderately dialyzable” with CKRT (level of evidence = D), “slightly dialyzable” with peritoneal dialysis (level of evidence = C), and “slightly dialyzable” with hemoperfusion (level of evidence = D). No data exist on intermittent hemodiafiltration, but it is expected to perform as well as hemodialysis, based on achievable urea clearance. In the rare scenario in which no antidote is available, high-efficiency hemodialysis would increase endogenous clearance at least 100% [278], i.e., “moderate” dialyzability.

Dialyzability of ethylene glycol metabolites

Glycolate: High glycolate clearance (> 150 mL/min) and high mass removal of glycolate (up to 50 g) are reported during hemodialysis [19, 164, 211]. There are reports of glycolate concentrations increasing modestly during ECTR suggesting that production surpassed elimination and that ADH blockade was inadequate [165]. Glycolate can also reaccumulate after ECTR, especially if ADH blockade is not continued [181, 185, 344]. Based on 4 patients in whom dialyzability could be assessed, glycolate was rated as “dialyzable” with hemodialysis (level of evidence = C) (Table 3).

Cessation

We recommend stopping ECTR when the AG (calculated as Na+ + K+– Cl−– HCO3.−) is < 18 mmol/Lstrong recommendation, very low-quality evidence
We suggest stopping ECTR when the EG is < 4 mmol/L (25 mg/dL)weak recommendation, very low-quality evidence
We suggest stopping ECTR when acid–base abnormalities are correctedweak recommendation, very low-quality evidence

Abstract

Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid–base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong (“we recommend”) or weak/conditional (“we suggest”), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8–12 mmol/L or anion gap 23–27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13054-022-04227-2.

Contents of the original publication

The section headings of the original.

Introduction
Physicochemical characteristics and toxicokinetics
Review of ethylene glycol toxicity
Methods
Results
Summary of the evidence: dialyzability
Summary of the evidence: pre-clinical data
Summary of the evidence: clinical data
Clinical recommendations
Research gap
Conclusion
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