The toxicokinetic and extracorporeal removal of bongkrekic acid during blood purification therapies: A case report

Bongkrekic acid (BA) poisoning can progress rapidly and lead to the failure of multiple organs, such as brain, liver and kidney. The mortality of BA poisoning is 40-100%. Little information is available on the toxicokinetic parameters of BA in human. Although hemodialysis is widely utilized for patients with severe BA poisoning, the exact amount of BA removed by hemodialysis is poorly documented. We analyzed toxicokinetic parameters, endogenous clearance and hemodialysis clearance in a patient with BA poisoning. A 27-year-old male developed symptoms of severe diarrhea, nausea, vomiting and weakness after eating rice noodles for more than one day. The patient developed multiple organ failures, especially the liver. Initial serum BA concentration was 0.5μg/mL. He received plasmapheresis, routing, and Oxiris-based Continuous Renal Replacement Therapy (CRRT). The whole blood, serum, urine and dialysate BA concentrations were collected and analyzed hourly. Toxicokinetic parameters relationships were determined using noncompartmental analysis. The clearances were determined using standard pharmacokinetic calculations. The disposition of BA was characterized by a long half-life (t1/2 of 102) and high max plasma (CL of 129,000 L/h/kg) following ingestion of contaminated food. The average serum clearance of BA during PE is remarkable higher than CRRT and the endogenous clearance. In contrast, the rates of decline in blood levels during the CRRT treatments were similar to the natural rate of decline. The total amount of BA removed by Plasmapheresis was 5.51mg. However, most CRRT failed to eliminate BA. We report a rare case of BA poisoning with a complication of liver failure and acute kidney damage. The patient expired, even with supportive care, plasmapheresis and hemodialysis. Analysis of whole blood, serum, urine and dialysate concentrations showed limited efficacy of CRRT in removing BA from blood. In contrast, there was significant extraction of BA from Plasmapheresis.