Charcoal hemoperfusion for aconite poisoning: Insights from a CKD case and complementary simulation experiments

Aconite contains four highly toxic diester-diterpene alkaloids (DDAs): aconitine, mesaconitine, hypaconitine, and jesaconitine. The efficacy of charcoal hemoperfusion (CHP) in treating aconite poisoning has recently been reported in several East Asian cases. This study evaluated the potential efficacy of CHP using two simulation experiments and one clinical case. One simulation examined the saturated adsorption capacity of activated charcoal for aconitine, whereas the other assessed the time course of perfusate aconitine concentrations at the inlet and outlet of an activated-charcoal column. The clinical case involved a 61-year-old female with stage V chronic kidney disease who underwent CHP for an electrical storm due to aconite poisoning. Her initial plasma DDA concentration was markedly higher than those reported in previous cases. This elevated concentration raises the possibility of substantial ingestion, although the exact amount cannot be determined. CHP was initiated 2 hr after ingestion and continued for 7 hr. In the simulations, activated charcoal showed a saturated adsorption capacity of 110 mg of aconitine per gram, and the column removed most aconitine in a single pass. In the clinical case, plasma DDA concentrations rapidly decreased after 7 hr of CHP, with a clearance rate of approximately 70 mL/min at a blood-flow rate of 100 mL/min. The terminal elimination half-life of plasma DDAs was 109.5 hr, likely reflecting the patient's underlying kidney disease. Taken together, these findings suggest that CHP may contribute to DDA elimination under severe renal impairment, although its broader clinical relevance remains uncertain.