Reactions 1169 - 15 Sep 2007

SLorazepam

Acute kidney injury, hyperosmolality and metabolicacidosis: case report

A 54-year-old man developed acute kidney injury,hyperosmolality and metabolic acidosis after receivinglorazepam; his symptoms were attributed to propylene glycoltoxicity.

The man, who had a history of multiple admissions foralcohol intoxication, was admitted with a right psoashaematoma. After 2 days, he developed severe alcoholwithdrawal. He started receiving an IV infusion of lorazepam[initial dosage not stated], IV fluids, thiamine andmultivitamins. On hospital day 5, he required higherlorazepam doses of > 5 mg/h, and was transferred to the ICU.On day 8, he developed severe metabolic acidosis, with a pHof 7.11, and acute kidney injury. He was suspected to havepropylene glycol toxicity secondary to a prolonged infusion ofhigh-dose lorazepam (about 10–20 mg/h averaged over8 days). He had received a cumulative lorazepam dose of4094mg over 7 days.

The man’s lorazepam infusion was immediately stopped.Laboratory investigations revealed the following: serumsodium 119 mmol/L, potassium 4.9 mmol/L, chloride92 mmol/L, CO2 13 mmol/L, blood urea nitrogen 5.0 mmol/L,creatinine 168.0 µmol/L, glucose 6.8 mmol/L, anion gap14 mmol/L, L-lactic acid 6.1 mmol/L, measured serumosmolality 395 mmol/kg, calculated serum osmolality249 mmol/kg and osmolal gap 145 mmol/kg. Over the nextfew hours, his condition dramatically deteriorated. Herequired intubation and haemodynamic support. He receiveda dose of IV fomepizole, and underwent emergencyhaemodialysis for 4 hours. A blood sample obtained prior tohaemodialysis revealed a serum propylene glycol level of810 mg/dL, confirming a diagnosis of propylene glycol toxicity.He received daily haemodialysis for the following 5 days. Afterthe second session, his osmolal gap had improved to39 mmol/kg. Over the next week, he showed gradual clinicaland metabolic improvements.Zar T, et al. Acute kidney injury, hyperosmolality and metabolic acidosisassociated with lorazepam. Nature Clinical Practice. Neurology 3: 515-520, No. 9,Sep 2007 - USA 801093357

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Reactions 15 Sep 2007 No. 11690114-9954/10/1169-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved