Caffeine clearance in severe intoxication: a comparative case series of hemodialysis, hemoadsorption, and continuous kidney replacement therapy

Extracorporeal treatments are effective in managing severe caffeine intoxication. We evaluated caffeine clearance in three patients treated with hemodialysis, hemoadsorption, or continuous kidney replacement therapy.
A 49-year-old woman with alcoholic liver cirrhosis underwent hemodialysis for serum caffeine concentration of 141 mg/L; clearance was 68.6 mL/min, reducing concentration below toxicity at 63.2 h post-admission. A 19-year-old woman with a polypharmacy overdose received hemoadsorption for an initial concentration of 194 mg/L; clearance was 50.1 mL/min, with a subtoxic concentration at 23.8 h post-admission. A 20-year-old man with a concentration of 181 mg/L experienced cardiopulmonary arrest and underwent veno-arterial extracorporeal membrane oxygenation. Continuous kidney replacement therapy achieved 9.6 mL/min clearance, resolving toxicity at 79.8 h post-admission. All patients recovered without sequelae.
Hemodialysis resulted in the highest caffeine clearance, whereas hemoadsorption normalized serum caffeine concentrations sooner than hemodialysis. However, hemoadsorption was administered only briefly owing to circuit clotting, limiting its overall effectiveness. Continuous kidney replacement therapy provided lower caffeine clearance but remained feasible in unstable patients under extracorporeal membrane oxygenation.
Hemodialysis and hemoadsorption offered high caffeine clearance and rapid detoxification, while continuous kidney replacement therapy was useful when other modalities were unsuitable. Further research should define optimal modality selection.