What is the treatment for ethylene glycol poisoning with transaminitis (elevated liver enzymes)?

Treatment of Ethylene Glycol Poisoning with Transaminitis

For ethylene glycol poisoning with transaminitis, treatment should include immediate administration of fomepizole as the first-line antidote, along with hemodialysis for patients with severe poisoning, metabolic acidosis, or renal dysfunction. 1, 2

Initial Assessment and Diagnosis

• Suspect ethylene glycol poisoning based on:
  • History of ingestion
  • Elevated anion gap metabolic acidosis
  • Increased osmolal gap
  • Presence of oxalate crystals in urine
  • Documented serum concentration >20 mg/dL 2, 3
  • Transaminitis (elevated liver enzymes) may be present but is not a primary diagnostic criterion

Treatment Algorithm

1. Antidotal Therapy

• First-line: Fomepizole 2, 3

  • Loading dose: 15 mg/kg IV over 30 minutes
  • Maintenance dose: 10 mg/kg IV every 12 hours for 4 doses, then 15 mg/kg every 12 hours
  • Continue until ethylene glycol levels are <20 mg/dL and patient is asymptomatic with normal pH
  • Do not use polycarbonate syringes or needles when administering fomepizole 3

• Alternative: Ethanol (if fomepizole unavailable)

  • Less predictable efficacy and requires more intensive monitoring 2

2. Hemodialysis Indications

Initiate hemodialysis if ANY of the following criteria are met:

• Ethylene glycol concentration >50 mmol/L (>310 mg/dL)
• Osmol gap >50
• Glycolate concentration >12 mmol/L
• Anion gap >27 mmol/L
• Severe acidemia (pH <7.20)
• Acute kidney injury (KDIGO stage 2 or 3)
• Coma or seizures 1, 2

3. Hemodialysis Considerations

• Preferred modality: Intermittent hemodialysis over other extracorporeal treatments 1, 2
• Fomepizole dosing during hemodialysis: Increase frequency to every 4 hours 3
• Cessation criteria:
  • Anion gap <18 mmol/L
  • Ethylene glycol concentration <4 mmol/L (<25 mg/dL)
  • Acid-base abnormalities corrected 1, 2

4. Management of Transaminitis

• Transaminitis itself does not alter the primary treatment approach for ethylene glycol poisoning
• Monitor liver function tests during treatment
• Supportive care for liver function as needed

5. Supportive Care

• IV fluid resuscitation
• Correction of metabolic acidosis with sodium bicarbonate
  • Target serum bicarbonate >15-18 mEq/L 2
• Electrolyte monitoring and correction, especially potassium, calcium, and phosphate
• Monitor for hypoglycemia 2

Clinical Pearls and Pitfalls

• Important: The presence of transaminitis does not change the fundamental approach to ethylene glycol poisoning treatment
• Caution: Fomepizole is dialyzable; dosing must be adjusted during hemodialysis 3
• Pitfall: Relying solely on ethylene glycol concentration for treatment decisions without considering acid-base status or renal function
• Key point: Early administration of fomepizole prevents the formation of toxic metabolites and subsequent renal injury 4
• Warning: Do not delay treatment while waiting for ethylene glycol levels; begin treatment based on clinical suspicion and metabolic abnormalities 2, 3

Prognosis

• Early treatment with fomepizole before significant metabolic acidosis or renal injury develops leads to excellent outcomes 4, 5
• Patients with anion gap <24 mmol/L treated with fomepizole have minimal risk of death or progression of acute kidney injury 5
• Poor prognostic indicators include:
  • Delayed presentation
  • Severe acidosis at presentation
  • Elevated glycolate levels (>12 mmol/L)
  • Pre-existing renal dysfunction 1, 4