When is dialysis indicated in patients with severe alcohol toxicity, particularly those with acute kidney injury or impaired renal function?

Dialysis Indications in Alcohol Toxicity

Dialysis is NOT routinely indicated for simple ethanol intoxication, but should be strongly considered for toxic alcohol poisoning (methanol, ethylene glycol) with severe metabolic acidosis, renal impairment, or life-threatening clinical features, and may be life-saving in rare cases of severe ethanol poisoning with refractory coma and hemodynamic instability.

Toxic Alcohols (Methanol, Ethylene Glycol) - Strong Indications

Absolute Indications for Hemodialysis

• Initiate hemodialysis immediately for ethylene glycol poisoning when glycolate concentration >12 mmol/L, anion gap >27 mmol/L, or presence of coma, seizures, or acute kidney injury 1
• Perform hemodialysis for methanol poisoning when blood methanol level >50 mg/dL (>15.6 mmol/L), known ingestion exceeding minimal lethal dose (30 mL), evidence of acidosis, or visual/mental status abnormalities 2
• Consider hemodialysis for ethylene glycol with glycolate 8-12 mmol/L or anion gap 23-27 mmol/L 1

Technical Specifications

• Use intermittent hemodialysis as first-line modality with high-flux membranes, blood flow >250 mL/min, and modified bicarbonate bath enriched with phosphorus and potassium 1, 3
• Adjust fomepizole dosing to every 4 hours during hemodialysis, as it is dialyzable 1
• Continue hemodialysis until anion gap normalizes (<18 mmol/L) and toxin levels are undetectable, not based solely on clinical improvement 1

Ethanol Intoxication - Rare Indications

Life-Threatening Scenarios Only

• Consider hemodialysis for severe ethanol poisoning only when blood ethanol levels are markedly elevated (>136 mmol/L or ~630 mg/dL) with refractory coma, shock requiring vasopressors, and failure of conservative management 4
• Hemodialysis rapidly reduces ethanol concentrations when conservative treatment (mechanical ventilation, IV fluids, vasopressors) fails to improve clinical status over 4 hours 4
• The osmole gap may serve as an indicator to identify patients requiring hemodialysis, though no validated algorithm exists for ethanol-only intoxication 5

When NOT to Dialyze

• Standard ethanol intoxication does NOT require dialysis, as supportive care with airway protection, IV fluids, and monitoring is sufficient in the vast majority of cases 4, 5
• The decision for hemodialysis in ethanol poisoning should only be made when benefits clearly outweigh risks and costs, which is exceedingly rare 5

Alcoholic Liver Disease Context

Acute Kidney Injury in Alcoholic Hepatitis

• Nephrotoxic drugs including diuretics should be avoided in severe alcoholic hepatitis, as acute kidney injury is an early manifestation of multi-organ failure 6
• Diuretics should be stopped temporarily when serum sodium decreases to <120-125 mmol/L in cirrhotic patients 6
• Dialysis indications in alcoholic hepatitis follow standard acute kidney injury criteria (KDIGO stage 2-3), not toxin-specific criteria 6

Critical Pitfalls to Avoid

• Do not delay hemodialysis for toxic alcohols based on normal anion gap if osmolal gap is elevated, as early ingestion presents with high osmolal gap before toxic metabolites accumulate 7
• Do not stop hemodialysis based solely on improving pH; continue until specific cessation criteria are met 1
• Recognize that false lactate elevation can occur with ethylene glycol due to cross-reaction with L-lactate oxidase 7
• Early hemodialysis in toxic alcohol ingestion prevents renal failure and improves neurological outcomes, even before severe acidosis develops 3, 7
• The interval from ingestion to treatment is more important than initial biochemical status for visual outcomes in methanol poisoning 2