Extracorporeal therapies in the management of paraquat poisoning: a comprehensive review of current evidence

INTRODUCTION: Paraquat (PQ) poisoning has a high mortality rate due to rapid systemic distribution and oxidative organ damage, particularly in the lungs. Conventional therapies are often inadequate, prompting interest in extracorporeal therapies to enhance PQ clearance. METHODS: This narrative review synthesizes current evidence on hemoperfusion (HP), continuous renal replacement therapy (CRRT), hemodiafiltration (HDF), haemodialysis (HD) and therapeutic plasma exchange (TPE) in PQ poisoning. Studies were evaluated for therapeutic mechanisms, clinical outcomes and optimal implementation strategies. RESULTS: Early and repeated HP, especially within 4-6 h post-ingestion, improves survival by directly adsorbing PQ. CRRT supports renal function and facilitates sustained toxin removal, with the best outcomes observed when combined with HP. HDF allows prolonged clearance but has limited supporting data. HD, while useful for managing acute kidney injury, appears ineffective for PQ elimination and may increase mortality. TPE shows potential benefits in severe cases if administered early, but evidence is limited to small studies. Combination therapies (e.g. HP with CRRT or HD) demonstrate synergistic effects in improving survival and organ support. CONCLUSIONS: Extracorporeal therapies, particularly early HP and HP combined with CRRT, are promising strategies in PQ poisoning. HD should not be the primary detoxification method but remains important for supportive care. TPE may be beneficial in selected cases. Further randomized trials are needed to optimize treatment protocols and validate combined approaches.