Procainamide toxicity in a patient with acute renal failure

A patient developed acute renal failure while receiving oral procainamide (PA). This lead to severe PA and N-acetyl procainamide (NAPA) toxicity. Rebound of NAPA plasma levels postdialysis prolonged the toxicity, which was treated with hemodialysis, hemoperfusion, and combined hemodialysis-hemoperfusion. Because of the potential for PA and NAPA toxicity in patients with renal insufficiency, especially in patients with changing renal function due to acute renal failure, it is recommended that the use of PA be curtailed in this population and that another substitute antiarrhythmic agent be used.