Acute hemolysis and renal failure associated with charcoal hemoperfusion for valproic acid intoxication

Charcoal hemoperfusion is an effective treatment in acute drug intoxication with small volume of distribution. For certain drugs, clearance rates are higher with hemoperfusion than hemodialysis. We describe a patient with severe valproic acid overdose who developed severe hemolysis and acute renal failure related to charcoal hemoperfusion treatment. A 50‐year‐old female was admitted to the hospital following valproic acid overdose. Initial valproic acid level was 73.6 mg/L, and she was treated with oral activated charcoal. Four hours later she developed mental status changes with valproic acid level at 490.9 mg/L and prolonged QT interval. Charcoal hemoperfusion was started with blood flow rate 400 ml/min. Patient developed bleeding with evidence of severeBefore( *C.H.) After (C.H.)Hemoglobin 12.1 gm/DL 7.6 gm/DL Hematocrit 35.5 gm/DL 21.1 gm/DL Platelet count 268,000 tho/ul 43,000 tho/ul L.D.H 90 IU/L 2494 IU/L Valproic Acid 490.9 mg/L 74.1 mg/L*C.H. (Charcoal Hemoperfusion) Blood – evidence of massive hemolysisintra‐vascular hemolysis, shown in table (no evidence of HUS/TTP). She received transfusion of packed red blood cells, platelets, and fibrin. Over the next few days she developed oligouric acute renal failure requiring hemodialysis for 2 weeks. Eventually hemolysis resolved and the renal function improved (kidney biopsy was consistent with acute tubular necrosis). To our knowledge, this is the first reported case of severe intravascular hemolysis occurring during the charcoal hemoperfusion treatment. Etiology includes mechanical trauma to the red cells, probably related to high blood flow rate through the charcoal column.