Abstract
Background A 54-year-old male with a history of multiple admissions for alcohol intoxication was admitted to hospital with right flank pain. He received a high-dose lorazepam infusion for alcohol withdrawal during hospitalization and developed severe hyperosmolality, high anion gap metabolic acidosis, and acute kidney injury on his eighth day of hospitalization.
Investigations Serum chemistries, arterial blood gas analysis, and measurement of serum propylene glycol, ethylene glycol and methanol levels.
Diagnosis Propylene glycol toxicity.
Management Discontinuation of lorazepam infusion, administration of fomepizole, hemodialysis for five consecutive days, hemodynamic support, and follow-up of serum osmolality as a measure of propylene glycol decay.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on SpringerLink
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
References
Wilson KC et al. (2005) Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study. Chest 128: 1674–1681
Arroliga AC et al. (2004) Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Crit Care Med 32: 1709–1714
Mullins ME and Barnes BJ (2002) Hyperosmolar metabolic acidosis and intravenous lorazepam. N Engl J Med 347: 857–858
Tayar J et al. (2002) Severe hyperosmolar metabolic acidosis due to a large dose of intravenous lorazepam. N Engl J Med 346: 1253–1254
Tuohy KA et al. (2003) Agitation by sedation. Lancet 361: 308
Yaucher NE et al. (2003) Propylene glycol-associated renal toxicity from lorazepam infusion. Pharmacotherapy 23: 1094–1099
Romanski SA and McMahon MM (1999) Metabolic acidosis and thiamine deficiency. Mayo Clic Proc 74: 259–263
Reynolds HN et al. (2000) Hyperlactatemia, increased osmolar gap and renal dysfunction during continuous lorazepam infusion. Crit Care Med 28: 1631–1634
Morshed KM et al. (1994) Acute toxicity of propylene glycol: an assessment using cultured proximal tubule cells of human origin. Toxicol Sci 23: 38–43
Hayman M et al. (2003) Acute tubular necrosis associated with propylene glycol from concomitant administration of intravenous lorazepam and trimethoprim-sulfamethoxazole. Pharmacotherapy 23: 1190–1194
Sturgill BC et al. (1982) Renal tubular necrosis in burn patients treated with topical polyethylene glycol [abstract]. Lab Invest 46: 81A
Yorgin PD et al. (1997) Propylene glycol-induced proximal renal tubular cell injury. Am J Kid Dis 30: 134–139
Yip L (2004) Other alcohols, glycols, and glycol ethers. In Medical Toxicology, edn 3 1237–1239 (Eds Dart RC et al.) Philadelphia: Lippincott Williams & Wilkins
Neale BW et al. (2005) Propylene glycol-induced lactic acidosis in a patient with normal renal function: a proposed mechanism and monitoring recommendations. Ann Pharmacother 39: 1732–1735
Jorens PG et al. (2004) Unusual D-lactic acid acidosis from propylene glycol metabolism in overdose. J Toxicol Clin Toxicol 42: 163–169
Chicella M et al. (2002) Propylene glycol accumulation associated with continuous infusion of lorazepam in pediatric intensive care patients. Crit Care Med 30: 2752–2756
Cawley MJ (2001) Short-term lorazepam infusion and concern for propylene glycol toxicity: case report and review. Pharmacotherapy 21: 1140–1144
Barnes BJ et al. (2006) Osmolal gap as a surrogate marker for serum propylene glycol concentrations in patients receiving lorazepam for sedation. Pharmacotherapy 26: 23–33
Brooks DE and Wallace KL (2002) Acute propylene glycol ingestion. J Toxicol Clin Toxicol 40: 513–516
Parker MG et al. (2002) Removal of propylene glycol and correction of increased osmolar gap by hemodialysis in a patient on high dose lorazepam infusion therapy. Intensive Care Med 28: 81–84
Al-Khafaji AH et al. (2002) Propylene glycol toxicity associated with lorazepam infusion in a patient receiving continuous veno-venous hemofiltration with dialysis. Anesth Analg 94:1583–1585
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing financial interests.
Rights and permissions
About this article
Cite this article
Zar, T., Yusufzai, I., Sullivan, A. et al. Acute kidney injury, hyperosmolality and metabolic acidosis associated with lorazepam. Nat Rev Nephrol 3, 515–520 (2007). https://doi.org/10.1038/ncpneph0573
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1038/ncpneph0573
This article is cited by
-
Assessing Propylene Glycol Toxicity in Alcohol Withdrawal Patients Receiving Intravenous Benzodiazepines: A One-Compartment Pharmacokinetic Model
European Journal of Drug Metabolism and Pharmacokinetics (2018)
-
Molecular interaction between natural IgG and ficolin – mechanistic insights on adaptive-innate immune crosstalk
Scientific Reports (2014)
-
Acute kidney injury with medazepam-hyoscine buthylbromide
Wiener klinische Wochenschrift (2014)
-
Natural IgG antibodies provide innate protection against ficolin-opsonized bacteria
The EMBO Journal (2013)