Is alcoholic intoxication a contraindication for dialysis?

Alcoholic Intoxication and Dialysis

Alcoholic intoxication is not a contraindication for dialysis; in fact, hemodialysis is a potentially life-saving treatment for severe alcohol poisoning and should be considered when patients present with life-threatening ethanol, methanol, or ethylene glycol intoxication.

When Dialysis is Indicated for Alcohol Intoxication

Severe Ethanol Poisoning

• Hemodialysis should be considered for patients with severe ethanol intoxication presenting with coma, shock, or markedly elevated blood alcohol levels that fail to respond to conservative management. 1
• In documented cases, hemodialysis rapidly reduced blood ethanol concentrations with prompt restoration of consciousness in patients who showed minimal improvement (only 16% reduction) after 4 hours of conservative treatment. 1
• Emergency hemodialysis has been successfully used to manage severe ethanol intoxication when supportive care alone is insufficient. 2

Toxic Alcohol Ingestions (Methanol and Ethylene Glycol)

• For methanol poisoning, prompt hemodialysis is recommended when blood methanol levels exceed 50 mg/dL, when ingestion exceeds the minimal lethal dose (30 mL), or when acidosis or visual/neurologic abnormalities develop. 3
• The EXTRIP workgroup strongly recommends using intermittent hemodialysis as the preferred extracorporeal treatment modality for ethylene glycol poisoning when available. 4
• Early hemodialysis with high-flux membranes should be performed pre-emptively in severe toxic alcohol intoxications to remove both the parent compound and its metabolites, even before severe acidosis develops. 5

Clinical Scenarios Requiring Dialysis

Metabolic Indicators

• High anion gap metabolic acidosis with elevated osmolar gap warrants consideration for dialysis. 6, 5
• Median pH of 7.04 or lower, bicarbonate <10 mmol/L, and anion gap >29 mmol/L are typical presentations successfully treated with hemodialysis. 5
• A high index of suspicion should be raised when encountering high osmolar gap with normal anion gap in early ingestions, as this may represent toxic alcohols before metabolism to toxic byproducts. 6

Neurologic Compromise

• Patients unable to protect their airway or presenting with altered mental status ranging from severe intoxication to coma benefit from emergent hemodialysis. 6
• The interval from ingestion to treatment is more important than initial biochemical status for preventing permanent complications. 3

Optimal Dialysis Prescription for Alcohol Poisoning

Technical Parameters

• Use large surface area dialyzer with high-flux membrane 5
• Blood flow rate should exceed 250 mL/min 5
• Modified bicarbonate bath enriched with phosphorus and potassium to prevent HD-induced electrolyte depletion 5
• Extended treatment sessions to maximize clearance 5

Expected Outcomes

• Hemodialysis corrects metabolic acidosis and osmolal abnormalities in all cases when implemented early. 5
• Mortality rates as low as 7% have been achieved with pre-emptive hemodialysis approach. 5
• Fast recovery of neurological status and prevention of renal failure occur with early intervention. 6

Important Caveats

Concurrent Therapy Required

• Ethanol or fomepizole administration is vital concurrent therapy for methanol and ethylene glycol poisoning to inhibit alcohol dehydrogenase and prevent formation of toxic metabolites. 3, 6, 5
• Supportive care including mechanical ventilation, vasopressors, and inotropics may be necessary during treatment. 1

Co-ingestion Considerations

• When multiple toxic alcohols are co-ingested, the kinetics of metabolism are altered, making early dialysis even more critical. 6
• False elevation of lactate can occur with ethylene glycol ingestion due to cross-reaction with L-lactate oxidase in analyzers. 6

Chronic Dialysis Patients

• For patients on maintenance dialysis, the American College of Cardiology recommends complete abstinence from alcohol, particularly with triglycerides ≥500 mg/dL, or restriction to maximum 2 drinks/day for men and 1 drink/day for women if triglycerides are lower. 7
• Alcohol provides empty calories while interfering with adequate protein and nutrient intake, which is already challenging in dialysis patients. 7