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Table 4 General guidance on chelation therapy and extracorporeal blood purification (EBP) in oliguric or anuric patients with lead and/or arsenic poisoning a

From: Treatment of lead and arsenic poisoning in anuric patients – a case report and narrative review of the literature

Heavy metal poisoning Chelation EBP Modality
Acute severe Pb poisoning with encephalopathy 1st line: BAL 4 mg/kg IM every 4-6  h [3, 22]
AND
CaNa2EDTA 25-50 mg/kg (max 3 g) IV over 24 h on CRRT,
begin 4 h after BAL [41, 42, 44]
HDF or high-flux HD
CRRT if unstable or BAL is used
2ndline: CaNa2EDTA 1 g IV over 1 h, give 1–3 h before HD or 25-50 mg/kg (max 3 g) IV over 24 h on CRRT [41, 42, 44]
OR
BAL 4 mg/kg IM every 4-6 h on CRRT [3, 22]
3rd line: DMPS 3-5 mg/kg (max 250 mg) IV every 4 h [49,50,51] b
DMSA c
Acute Pb poisoning without encephalopathy but still requiring chelation 1st line: CaNa2EDTA 1 g IV over 1 h, give 1–3 h before HD or 25-50 mg/kg (max 3 g) IV over 24 h on CRRT [41, 42, 44] HDF or high-flux HD
CRRT if unstable or BAL is used
2nd line: DMPS 100-300 mg PO every 8 h [49, 52, 53]b
3rd line: BAL 4 mg/kg IM every 4-6 hours [3, 22]
DMSA c
Chronic Pb poisoning without encephalopathy requiring chelation 1st line: CaNa2EDTA 1 g IV over 1 h, give 1–3 h before HD or 25-50 mg/kg (max 3 g) IV over 24 h on CRRT [41, 42, 44] HDF or high-flux HD
CRRT if unstable or BAL is used
PD could be considered if CaNa2EDTA is used
2nd line: DMPS 100-300 mg PO every 8 h [49, 52, 53]b
3rd line: BAL 4 mg/kg IM every 4-6 h [3, 22]
DMSA c
Ars poisoning (acutely ill) 1st line: DMPS 3-5 mg/kg (max 250 mg) IV every 4 h [49,50,51] HDF or high-flux HD
CRRT if unstable or BAL is used
2nd line: BAL 4 mg/kg IM every 4-6 h [3, 22]
DMSA c
Ars poisoning (chronic / subacute) d DMPS 100-300 mg PO every 8 h [52, 53] HDF or high-flux HD
  1. CRRT continuous renal replacement therapy, HDF hemodiafiltration, HD hemodialysis, PD peritoneal dialysis, MWCO molecular weight cut-off
  2. a The above chelation dosing recommendations are a result of our literature review and personal experience and should be considered as a guideline only. We strongly recommend discussion with a poison center or medical toxicologist in conjunction with these recommendations for each individual case, therapeutic endpoints of chelation and side-effects. 2nd and 3rd line treatments may be considered if 1st line treatments are unavailable
  3. b DMPS dose for Pb chelation is extrapolated from the Ars chelation dose
  4. c The efficacy DMSA with severe renal impairment is unclear, but it may be considered in conjunction with a high MWCO dialysis membrane if the other chelators are unavailable. For both Pb and Ars: 10 mg/kg PO every 8 h for 5 days, then 10 mg/kg every 12 h [33]
  5. d The role of chelation, if any, in chronic/subacute Ars poisoning is unclear
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