Veterinary Clinical Reference · EBPT

Extracorporeal Blood
Purification Therapies
(EBPT)
in Veterinary Medicine

Evidence-based guidance for hemodialysis/hemofiltration, hemoperfusion, and therapeutic plasma exchange in the management of acute toxicoses in dogs, cats, and horses — synthesizing IRIS guidelines and peer-reviewed veterinary literature.

Dog (Canine) Cat (Feline) Horse (Equine)
Decision Aid → Browse Toxins PK Table
3 EBPT Modalities
HD · HP · TPE Techniques
IRIS 2024–25 Guideline Standard
16+ Toxins Covered
// Clinical Tool

EBPT Decision Aid

Select toxin and clinical parameters for modality guidance. Always consult a veterinary internist or specialist; contact ASPCA Animal Poison Control (+1 888-426-4435) for emergency guidance.

Veterinary EBPT Selector

Select a toxin, species, and clinical parameters for evidence-informed modality recommendations.

Recommendation

For educational reference only. Not a substitute for specialist consultation. ASPCA Animal Poison Control: +1 888-426-4435. EBPT availability varies widely — always call ahead before referral to confirm the centre can provide ECT treatment, and follow their recommendations regarding indications and choice of modality. Find a veterinary dialysis unit near you at Queen of the Nephron.
// Clinical Guidance

When to Consider EBPT

Key indications and clinical triggers for initiating extracorporeal blood purification therapy in veterinary patients.

When to Initiate EBPT

  • GI decontamination incomplete, failed, or contraindicated
  • Life-threatening dose ingested relative to toxic threshold — act early, not reactively
  • No antidote available or antidote response insufficient
  • Impaired endogenous clearance (AKI, hepatic dysfunction) — drug elimination may be diminished and half-life extended
  • Progressive neurological, renal, or cardiovascular deterioration
  • Toxin has favorable pharmacokinetics for EBPT removal (see PK Table)
  • Circuit volume considerations in small patients — blood prime or MCHP when extracorporeal circuit volume exceeds ~10–15% of estimated blood volume (dogs ~80–90 mL/kg; cats ~60 mL/kg; horses ~80 mL/kg). Confirm circuit volume with the referral centre as it varies between platforms.
// Core Concepts

Veterinary EBPT Principles

Foundational clinical principles specific to extracorporeal blood purification in companion animal and large animal medicine.

01 // TIMING

Act Before Organ Damage

EBPT provides a critical window after absorption but before irreversible organ injury. Do not wait for AKI or neurological deterioration to confirm the indication — treat the toxicokinetic risk, not just the observed signs.

02 // CIRCUIT VOLUME

Match Circuit to Patient Size

Always calculate estimated blood volume (Dog: 80–90 mL/kg; Cat: 60 mL/kg) and compare to the extracorporeal circuit volume before initiating. Circuit volume varies between platforms — confirm with the referral centre. Consider MCHP or blood prime for patients where circuit volume exceeds ~10–15% of EBV.

03 // PK SELECTION

Match Modality to Properties

Use protein binding, Vd, MW, and lipophilicity to select modality. NSAIDs → HP and TPE both effective. Ethylene glycol, baclofen → HD/HF. In-series HP+HD provides dual-mechanism clearance for complex cases.

04 // ADJUNCT CARE

EBPT is Not Sole Therapy

Continue IV fluids, gastroprotection, antidotes (4-MP for EG; cyproheptadine for 5-HTP; ILE for lipophilic toxins), nutritional support, and pain management throughout EBPT. Do not pause supportive care for sessions.

05 // ANTICOAGULATION

Circuit Anticoagulation

Systemic heparin is standard; monitor ACT (target 1.5–2× baseline) or aPTT. Citrate regional anticoagulation is an option in patients with active bleeding risk. Platelet counts transiently decrease with HP — monitor closely.

06 // EVIDENCE

Case-Level Evidence Predominates

Most veterinary EBPT data are retrospective case series (largest: 434 dogs, Chalifoux 2023) and case reports. No veterinary RCTs exist. IRIS 2024–2025 guidelines represent current best-practice consensus from field experts.

07 // REBOUND

Post-EBPT Rebound Effect

After EBPT, toxin redistributes from peripheral tissues back into blood. Clinically significant for lipophilic drugs (NSAIDs) and long-half-life compounds (naproxen, ~74 h in dogs). Monitor levels post-session and repeat TPE/HP if needed.

08 // REFERRAL

Build Your Referral Network

EBPT requires specialised equipment and trained staff. Establish referral relationships with veterinary dialysis centres early. Always call ahead before referral to confirm the centre can provide ECT and follow their recommendations on indications and modality choice. Find a unit near you at queenofthenephron.com.

// Techniques

Extracorporeal Modalities

Three primary extracorporeal blood purification therapies (EBPT) used in veterinary toxicology, each with distinct mechanisms, circuit requirements, and indications for specific toxicoses. Modality selection should follow a stepwise approach integrating pharmacokinetic assessment and clinical severity (Ghannoum et al. 2014; Vigani & Cowgill 2017).

Hemodialysis / Hemofiltration HD/HF

Blood passes across a semipermeable membrane. In hemodialysis, toxins are removed primarily by diffusion against counter-current dialysate. In hemofiltration (HF), large volumes of ultrafiltrate are removed by convection and replaced with substitution fluid, enabling clearance of larger molecules up to ~40,000 Da. HD in experimental dogs dates to 1913 and remains the most established EBPT modality for small animal toxicoses (Langston 2017; Cowgill & Francey 2012). Circuit volume varies by platform and must be carefully considered in small patients.

Primary MechanismDiffusion (HD) + Convection (HF)
Optimal MW — Low-efficiency HD<500 Da
Optimal MW — High-efficiency HD<1,500 Da
Optimal MW — Hemofiltration<40,000 Da
Protein Binding<80% preferred
Volume of Distribution<1 L/kg preferred
Volume ProcessedVaries by prescription

Hemoperfusion HP

Blood contacts activated carbon or resin cartridges directly — no dialysate is used. Toxins adsorb to the sorbent surface. Superior to HD for high-protein-bound, lipophilic, and larger molecules. Ideal for NSAID toxicities. Manual carbon HP (MCHP) uses a smaller circuit, making it feasible in very small patients. Sorbent technology and circuit design reviewed in Ronco et al. 2022.

Primary MechanismAdsorption (sorbent)
Optimal MW500–40,000 Da
Protein BindingHigh acceptable
Volume of Distribution<2 L/kg preferred
Volume Processed10–20 blood vol./session

Plasma Exchange TPE

Plasma is separated from blood cells and replaced with fresh frozen plasma or albumin. Effective for highly protein-bound toxins — NSAIDs (98–99% protein-bound) are a key veterinary indication. Both TPE and HP are effective for NSAID toxicosis. A single TPE session reduces plasma NSAID levels by 51–85.5% in dogs. Circuit volume varies by platform and may require blood prime in small patients.

Primary MechanismPlasma Removal + Replacement
Protein Binding>90% (highly effective)
Volume of Distribution<0.5 L/kg preferred
Volume Processed1.2–2.0 plasma vol./session
// Evidence Base

Veterinary Toxin Recommendations

EBPT recommendations for common veterinary toxicoses in dogs, cats, and horses. Based on pharmacokinetic properties and published veterinary and human comparative literature (Cowgill & Francey 2012; Ghannoum et al. 2020; Roberts & Buckley 2015).

Toxin / Agent Species Category Hemodialysis/Hemofiltration (HD/HF) Hemoperfusion (HP) Plasma Exchange (TPE) Notes
// Drug Properties

Pharmacokinetics Reference Table

Key physicochemical and pharmacokinetic parameters that govern EBPT efficacy. Colour coding reflects suitability for removal by each modality.

Effective
Not effective
Unknown
Drug / Toxin Mol. Weight (Da) Protein Binding Vol. Distribution (L/kg) Water Solubility LogP Primary Clearance Half-life (species) HD/HF HP TPE
Interpretation notes: Protein binding <80%, Vd <1 L/kg, and good water solubility favour hemodialysis/hemofiltration. MW <500 Da suits low-efficiency HD; <1,500 Da suits high-efficiency HD; <40,000 Da can be cleared by hemofiltration. LogP (octanol–water partition coefficient) reflects lipid solubility: values <1 indicate hydrophilic drugs favourable for HD/HF; values >3 indicate lipophilic drugs better suited to HP or TPE. High protein binding (>90%) and high lipophilicity (LogP >3) favour HP and TPE. Very high Vd (>5 L/kg) generally predicts poor EBPT efficacy regardless of modality. Data represent values for the primary species affected unless otherwise stated; veterinary pharmacokinetic data are limited for many compounds.
// Peer-Reviewed Evidence

References

Veterinary and comparative literature supporting EBPT recommendations, with emphasis on publications from 2002–2025.

12Vet Studies
22Human / EXTRIP
3Guidelines
2002–25Date Range
Veterinary Studies 12
#01 Vet — Multicenter Retrospective (n=434)
Outcomes of 434 Dogs with NSAID Toxicosis Treated with IV Fluids, Lipid Emulsion, or Therapeutic Plasma Exchange
Chalifoux NV, Butty EM, Mauro KD, et al.
Journal of Veterinary Internal Medicine. 2023;37(1):161–172.
Largest NSAID toxicosis outcomes study in veterinary medicine — 434 dogs from 5 US centres, 2015–2020. Compared IVF, ILE, TPE, and combinations. Key: 99% survival. Ibuprofen caused greater severity than carprofen (p=0.03). TPE group had lower AKI incidence. Higher baseline creatinine, longer presentation delay, and absent emesis predicted severity. Weight ≤7.1 kg increased AKI risk with naproxen.
DogsNSAIDsTPE434 patients
↗ PubMed: 36453531
#02 Vet — Multicenter Retrospective (n=62)
Outcomes of NSAID Toxicosis Treated with Therapeutic Plasma Exchange in 62 Dogs
Butty EM, Suter SE, Chalifoux NV, et al.
Journal of Veterinary Internal Medicine. 2022;36(5):1641–1647.
62 dogs with ibuprofen, carprofen, or naproxen overdose treated with TPE. Median ibuprofen dose: 533 mg/kg. TPE reduced plasma NSAID by 51–85.5% per session. Lower AKI incidence in TPE group. Overall survival 99%. Single TPE session sufficient for most cases.
DogsNSAIDsTPE
↗ PubMed: 35930372
#03 Vet — Pioneer Case Series (n=11)
Use of Therapeutic Plasma Exchange to Treat NSAID Overdose in Dogs
Rosenthal MG, Labato MA.
Journal of Veterinary Internal Medicine. 2019;33(2):596–602.
First case series establishing TPE for NSAID toxicosis in dogs. 11 cases (ibuprofen, naproxen, deracoxib). Single TPE session reduced NSAID levels 51–85.5%. All survived. Foundational paper establishing the veterinary evidence base for TPE in NSAID poisoning.
DogsNSAIDsTPE pioneer
↗ PubMed: 30698297
#04 Vet — Case Report (Cat + Dog, MCHP)
Manual Carbon Hemoperfusion for Meloxicam Toxicity in a Cat and Suspected Ibuprofen Toxicity in a Dog
Haire LE, Vitalo AD, Gonçalves RP, Lanaux TM.
Frontiers in Veterinary Science. 2024;11:1395967.
First report of manual carbon HP (MCHP) in small patients — reduced circuit volume compared to machine-based platforms. Cat plasma meloxicam reduced 44%. Both patients tolerated procedure. MCHP is feasible at any hospital with carbon filters and blood bank access — a key advance for centres without dedicated dialysis equipment.
CatDogManual HPSmall patients
↗ DOI: 10.3389/fvets.2024.1395967
#05 Vet — Case Report (Dog, HP+HD)
Activated Carbon Hemoperfusion and Hemodialysis for Meloxicam Overdose in a Dog
Covo M, et al.
Journal of Veterinary Emergency and Critical Care. 2025. DOI: 10.1111/vec.70062.
First report of activated carbon HP+HD in-series for meloxicam toxicosis in a dog. Basset Hound, 5.5 mg/kg meloxicam. 15 blood volumes over 207 min → 87.5% reduction in serum meloxicam. Greatest reduction in first hour. Self-limiting hematochezia only. Stable mild azotemia at 8-week follow-up.
DogMeloxicamHP+HD in-series
↗ DOI: 10.1111/vec.70062
#06 Vet — Case Report (Dog, 5-HTP)
Successful Treatment of 5-Hydroxytryptophan Intoxication Using Carbon Hemoperfusion, Hemodiafiltration, and Mechanical Ventilation in a Dog
Her J, Gordon D, Riggs A, et al.
Journal of Veterinary Emergency and Critical Care. 2024;34(2):186–192.
First report of carbon HP + hemodiafiltration for 5-HTP toxicosis (serotonin syndrome) in a dog. Patient required mechanical ventilation concurrently. Successful outcome despite critical presentation — demonstrates combined HP+CRRT as a lifesaving option for severe novel toxicoses.
Dog5-HTPHP + CRRT
↗ PubMed: 38247427
#07 Vet — Case Report (Dog, TPE+PP)
Treatment of Naproxen Overdose Using Therapeutic Plasma Exchange and Plasmaperfusion in a Dog
Studer KA, Iacovetta C.
Journal of Veterinary Internal Medicine. 2025;39(5):e70235.
8-year-old mixed breed dog (37.4 kg), naproxen 235–294 mg/kg. Combined TPE + plasmaperfusion. 2 plasma volumes exchanged over 140 min → 46% blood naproxen reduction. Subsequent PP added additional clearance. Discharged day 4; normal bloodwork at 5-day recheck. Demonstrates combined TPE+PP for long-half-life NSAIDs.
DogNaproxenTPE + Plasmaperfusion
↗ PMC: 12398282
#28 Vet — Comprehensive Review
Use of Extracorporeal Therapy in Veterinary Toxicologic Emergencies
Cowgill LD, Francey T.
Veterinary Clinics of North America: Small Animal Practice. 2012;42(4):827–846.
Foundational review of ECTR applications in veterinary toxicology. Covers indications, modality selection (HD, HP, TPE), pharmacokinetic principles governing dialyzability, and practical considerations for small animal patients. Established the conceptual framework for veterinary EBPT decision-making that remains in use today.
DogsCatsECTR overviewFoundational
↗ PubMed: 22720816
#29 Vet — Case Series (n=5, Dogs)
Hemodialysis for Treatment of Ethylene Glycol Intoxication in Dogs
Reineke EL, Thomas EK, Syring RS, Mazzaferro EM, Drobatz KJ.
Journal of Veterinary Emergency and Critical Care. 2013;23(4):404–410.
Reports outcomes of HD for ethylene glycol toxicosis in 5 dogs. Demonstrated effective clearance of EG and metabolites via hemodialysis. Supports the role of HD in managing canine toxic alcohol ingestions, particularly when fomepizole or ethanol therapy alone is insufficient.
DogsEthylene GlycolHD
↗ PubMed: 23855441
#30 Vet — Retrospective Review
Dialysis for Treatment of Intoxications in Dogs and Cats
Segev G, Bruchim Y, Leisner S, et al.
Journal of Veterinary Emergency and Critical Care. 2015;25(1):45–57.
Retrospective evaluation of dialysis outcomes for various intoxications in dogs and cats. Provides species-specific data on toxin clearance, complications, and survival. Key reference for the range of toxins treated with ECTR in veterinary patients and expected clinical outcomes.
DogsCatsMultiple toxinsOutcomes
↗ PubMed: 25470592
#31 Vet — Clinical Review
Hemodialysis for Treatment of Acute Intoxications in Dogs and Cats
Langston C.
Veterinary Clinics of North America: Small Animal Practice. 2017;47(6):1193–1212.
Comprehensive clinical review covering hemodialysis techniques, patient selection, and outcomes for acute intoxications in small animals. Addresses practical aspects including vascular access, prescription parameters, and monitoring. Discusses toxin-specific HD efficacy across ethylene glycol, lilies, NSAIDs, and other common veterinary toxicoses.
DogsCatsHD techniqueClinical review
↗ PubMed: 28802903
#32 Vet — Clinical Review
Extracorporeal Therapies for the Treatment of Intoxications in Dogs and Cats
Vigani A, Cowgill LD.
Journal of Veterinary Emergency and Critical Care. 2017;27(4):403–416.
Reviews all major ECTR modalities (HD, HP, TPE, CRRT) for veterinary intoxications. Compares modality-specific clearance mechanisms and provides practical guidance on modality selection based on toxin pharmacokinetics. Emphasizes the importance of early referral and matching the modality to the specific toxin properties.
DogsCatsModality comparisonAll ECTR
↗ PubMed: 28574616
Human / Comparative Studies 22
#08 Human — Systematic Review (EXTRIP)
ECTR for Salicylate Poisoning: Systematic Review from the EXTRIP Workgroup
Juurlink DN, Gosselin S, Kielstein JT, et al.
Annals of Emergency Medicine. 2015;66(2):165–181.
84 articles, 143 patients. HD recommended for altered mental status, ARDS, or failure of standard therapy. Salicylate pharmacokinetics closely mirror several veterinary toxins — principles directly translatable to small animal HD decision-making.
SalicylatesHDTranslational
↗ PubMed: 25987281
#09 Human — Review (ECTR Principles)
Extracorporeal Removal of Poisons and Toxins
Ghannoum M, Nolin TD, Lavergne V, Hoffman RS.
Clinical Journal of the American Society of Nephrology. 2020;15(10):1494–1502.
Authoritative review of the pharmacokinetic framework governing ECTR efficacy — Vd, protein binding, MW, water solubility, and ECTR clearance contribution. Comprehensive dialyzability table across toxin classes. The PK framework is identical to that applied in veterinary EBPT.
PharmacokineticsDialyzabilityTranslational
↗ PMC: 6730523
#10 Human — Cohort (Pediatric/Small Patient)
Comparison of Children Receiving ECTR at US Centres With and Without a Pediatric Nephrologist
Holstege CP, et al.
Clinical Toxicology. 2025. DOI: 10.1080/15563650.2025.2456109.
72 pediatric patients (2000–2024). Adult nephrologists used IHD 100%; pediatric nephrologists used CRRT in 52%. The small-patient technical challenge — matching circuit volumes, flow rates, and modality to small body size — is a direct parallel to veterinary small animal EBPT.
PediatricSmall patient analogy
↗ DOI: 10.1080/15563650.2025.2456109
#11 Human — Methodology (EXTRIP)
The EXTRIP Workgroup: Guideline Methodology
Lavergne V, Nolin TD, Hoffman RS, et al.
Clinical Toxicology. 2012;50(5):403–413.
Defines dialyzability criteria: ECTR clearance >30% of total clearance OR significant fraction removed in 6 h. AGREE-instrument approach and two-round Delphi consensus. The same pharmacokinetic criteria are applied in veterinary EBPT decision-making — making this a critical methodological reference.
EXTRIPMethodologyDialyzability criteria
↗ PubMed: 22578059
#12 Human — EXTRIP Systematic Review (Ethylene Glycol)
Extracorporeal Treatment for Ethylene Glycol Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, et al.
Critical Care. 2023;27:58.
226 articles, 446 patients (mortality 18.7%). ECTR recommended if ethanol used and EG >50 mmol/L, or glycolate >12 mmol/L, or severe features (coma, seizures, AKI). When glycolate ≤12 mmol/L, mortality only 3.6% — ECTR not better than standard care in this subgroup. Directly applicable to veterinary EG toxicosis in dogs and cats.
EXTRIPEthylene GlycolHD recommended
↗ PubMed: 36765419
#13 Human — EXTRIP Systematic Review (Baclofen)
Recommendations from the EXTRIP Workgroup on Extracorporeal Treatment for Baclofen Poisoning
Ghannoum M, Lavergne V, Gosselin S, et al.
Kidney International. 2021;100(4):720–736.
43 studies reviewed. EXTRIP suggests against ECTR for acute baclofen poisoning in addition to standard care. Suggests for ECTR in therapeutic baclofen toxicity with kidney impairment, especially with coma requiring mechanical ventilation. Relevant to veterinary baclofen toxicosis — note distinction between acute overdose and renal impairment scenarios.
EXTRIPBaclofenNuanced recommendation
↗ PubMed: 34358487
#14 Human — EXTRIP Systematic Review (Methotrexate)
Extracorporeal Treatment for Methotrexate Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Ghannoum M, Bouchard J, Bhatt M, et al.
Clinical Journal of the American Society of Nephrology. 2022;17(4):602–622.
92 articles, toxicokinetic data on 90 patients. Methotrexate moderately dialyzable by IHD. EXTRIP suggests against ECTR when glucarpidase is not administered, and recommends against ECTR when glucarpidase is given. Glucarpidase is preferred intervention. Relevant to veterinary oncology overdose cases where glucarpidase may not be available.
EXTRIPMethotrexateGlucarpidase preferred
↗ PubMed: 35236714
#15 Human — EXTRIP Systematic Review (Barbiturates)
Extracorporeal Treatment for Barbiturate Poisoning: Recommendations from the EXTRIP Workgroup
Mactier R, Laliberté M, Bhatt M, et al.
American Journal of Kidney Diseases. 2014;64(3):347–358.
617 articles, 538 patients. Long-acting barbiturates (phenobarbital) deemed dialyzable; short-acting barbiturates moderately dialyzable. ECTR recommended for severe poisoning to reduce coma duration and complications. Directly applicable to veterinary phenobarbital toxicosis — supports HD and HP+HD in-series.
EXTRIPPhenobarbitalHD recommended
↗ PubMed: 24998037
#16 Human — EXTRIP Systematic Review (Acetaminophen)
Extracorporeal Treatment for Acetaminophen Poisoning: Recommendations from the EXTRIP Workgroup
Gosselin S, Juurlink DN, Kielstein JT, et al.
Clinical Toxicology. 2014;52(8):856–867.
24 articles, 135 patients. NAC is mainstay; ECTR not warranted in most cases. ECTR suggested for massive overdose with mitochondrial dysfunction (early AMS + severe metabolic acidosis) and APAP >1000 mg/L without NAC, or >700 mg/L with mitochondrial dysfunction. Relevant to canine/feline acetaminophen toxicosis where NAC is primary treatment.
EXTRIPAcetaminophenNAC first-line
↗ PubMed: 25133498
#17 Human — EXTRIP Systematic Review (Digoxin)
Extracorporeal Treatment for Digoxin Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Mowry JB, Burdmann EA, Anseeuw K, et al.
Clinical Toxicology. 2016;54(2):103–114.
Digoxin deemed only slightly dialyzable due to very high Vd (~7–10 L/kg). EXTRIP recommends against ECTR for digoxin poisoning — Fab fragments (digoxin immune Fab) are the treatment of choice. Confirms veterinary PK table assessment: HD, HP, and TPE all ineffective for digoxin due to massive tissue distribution.
EXTRIPDigoxinECTR not recommended
↗ PubMed: 26795743
#18 Human — EXTRIP Systematic Review (Valproic Acid)
Extracorporeal Treatment for Valproic Acid Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Ghannoum M, Laliberté M, Bhatt M, et al.
Clinical Toxicology. 2015;53(5):454–465.
ECTR recommended for severe VPA poisoning with coma, cerebral edema, respiratory depression, or VPA >1300 mg/L. Valproic acid is dialyzable at supratherapeutic levels when protein binding is saturated. Relevant to veterinary VPA overdose — dogs receiving anticonvulsant therapy are at risk of iatrogenic toxicosis.
EXTRIPValproic AcidHD recommended if severe
↗ PubMed: 25950372
#19 Human — EXTRIP Systematic Review (Lithium)
Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Decker B, Goldfarb DS, Dargan PI, et al.
Clinical Journal of the American Society of Nephrology. 2015;10(5):875–887.
Lithium is highly dialyzable (low MW 7 Da, no protein binding, low Vd ~0.7 L/kg). ECTR recommended for severe poisoning with impaired kidney function, decreased consciousness, or life-threatening dysrhythmias. Rebound phenomenon well-documented — repeat sessions may be needed. Pharmacokinetic principles directly applicable to veterinary toxicology.
EXTRIPLithiumHighly dialyzable
↗ PubMed: 25583292
#20 Human — EXTRIP Systematic Review (Theophylline)
Extracorporeal Treatment for Theophylline Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Ghannoum M, Wiegand TJ, Liu KD, et al.
Clinical Toxicology. 2015;53(4):215–229.
Theophylline deemed dialyzable. ECTR recommended for severe poisoning with seizures, life-threatening arrhythmias, or theophylline >100 mg/L (acute) or >60 mg/L (chronic). HP and IHD both effective. Relevant to veterinary theobromine/caffeine toxicosis in dogs — methylxanthines share pharmacokinetic properties.
EXTRIPTheophyllineMethylxanthines
↗ PubMed: 25715736
#21 Human — EXTRIP Systematic Review (Methanol)
Extracorporeal Treatment for Methanol Poisoning: Recommendations from the EXTRIP Workgroup
Roberts DM, Yates C, Megarbane B, et al.
Critical Care Medicine. 2015;43(2):461–472.
Methanol highly dialyzable (low MW 32 Da, no protein binding). ECTR strongly recommended for severe poisoning with metabolic acidosis, visual disturbances, or methanol >70 mg/dL. Fomepizole as antidote adjunct. Parallel to veterinary ethylene glycol toxicosis — both are toxic alcohol poisonings requiring HD for metabolite clearance.
EXTRIPMethanolToxic alcohols
↗ PubMed: 25599466
#22 Human — EXTRIP Systematic Review (Carbamazepine)
Extracorporeal Treatment for Carbamazepine Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Ghannoum M, Yates C, Galvao TF, et al.
Clinical Toxicology. 2014;52(10):993–1004.
Carbamazepine moderately dialyzable. ECTR suggested for severe poisoning with prolonged coma, seizures, or life-threatening dysrhythmias refractory to standard care. HP preferred over HD for carbamazepine due to higher protein binding. Relevant to veterinary anticonvulsant toxicosis.
EXTRIPCarbamazepineHP preferred
↗ PubMed: 25283256
#23 Human — EXTRIP Systematic Review (Phenytoin)
Extracorporeal Treatment in Phenytoin Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Anseeuw K, Mowry JB, Burdmann EA, et al.
American Journal of Kidney Diseases. 2016;67(2):187–197.
Phenytoin moderately dialyzable. ECTR suggested in severe phenytoin poisoning refractory to standard care, especially with prolonged neurological dysfunction. High protein binding (~90%) limits HD efficacy; HP may be more effective. Relevant to veterinary phenytoin/anticonvulsant overdose scenarios.
EXTRIPPhenytoinAnticonvulsant
↗ PubMed: 26590448
#24 Human — EXTRIP Systematic Review (Metformin)
Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup
Calello D, Liu KD, Shields B, et al.
Critical Care Medicine. 2015;43(8):1716–1730.
Metformin dialyzable (low MW 129 Da, negligible protein binding). ECTR recommended for severe metformin-associated lactic acidosis (MALA) with pH ≤7.0 or lactate >20 mmol/L. HD is preferred modality. Relevant to veterinary metformin ingestion in dogs — accidental exposure to owner medications.
EXTRIPMetforminLactic acidosis
↗ PubMed: 25860204
#33 Human — Review (HD/HP History)
Hemodialysis and Hemoperfusion in the Treatment of Poisoning
Winchester JF.
Seminars in Dialysis. 2002;15(3):164–170.
Classic review of HD and HP history and principles in toxicology. Covers the evolution of extracorporeal approaches for poisoning, the development of activated charcoal hemoperfusion, and the comparative roles of HD vs. HP based on toxin properties. Provides historical context for modern ECTR protocols used in both human and veterinary medicine.
HDHPHistorical review
↗ PubMed: 12100731
#34 Human — Clinical Framework (EXTRIP)
A Stepwise Approach for the Management of Poisoning With Extracorporeal Treatments
Ghannoum M, Gosselin S, Nolin TD, Bhatt M, et al.
Seminars in Dialysis. 2014;27(4):362–370.
Provides a practical stepwise clinical algorithm for deciding when and how to use ECTR in poisoned patients. Integrates pharmacokinetic assessment (MW, Vd, protein binding), clinical severity, and antidote availability into a structured decision framework. Directly applicable to the veterinary EBPT decision-making process.
EXTRIPDecision frameworkClinical algorithm
↗ PubMed: 24738145
#35 Human — Systematic Review (ECTR Overview)
Extracorporeal Treatments for Poisoning: A Systematic Review
Roberts DM, Buckley NA.
Clinical Toxicology. 2015;53(7):573–580.
Broad systematic review of all ECTR modalities for poisoning, evaluating evidence quality and clinical outcomes across multiple toxin classes. Identifies gaps in the evidence base and highlights the reliance on case series and expert opinion. Underscores the need for standardized reporting and comparative effectiveness studies.
Systematic reviewAll ECTREvidence gaps
↗ PubMed: 26109388
#36 Human — Review (Critical Care)
Extracorporeal Treatment in the Management of Acute Poisoning
Jha V, Parameswaran S.
Indian Journal of Critical Care Medicine. 2018;22(3):183–190.
Reviews ECTR principles and applications in the critical care setting for acutely poisoned patients. Covers modality selection, timing of initiation, and practical considerations in resource-limited settings. Discusses HD, HP, and TPE with emphasis on pharmacokinetic determinants of extracorporeal clearance efficacy.
Critical careECTR overviewPractical guidance
↗ PubMed: 29657377
#37 Human — Technical Review (HP)
Hemoperfusion: Technical Aspects and State of the Art
Ronco C, Bellomo R, Kellum JA, et al.
Blood Purification. 2022;51(6):593–602.
Comprehensive technical review of hemoperfusion covering sorbent materials, cartridge design, circuit configuration, and emerging technologies. Evaluates activated charcoal, polymeric, and resin-based sorbents. Discusses HP alone and in-series with HD or CRRT. Directly relevant to understanding the HP technologies used in veterinary EBPT.
HemoperfusionSorbent technologyTechnical review
↗ PubMed: 35172313
Guidelines & Consensus Documents 3
#25 Vet Guidelines — IRIS IHD 2024
IRIS Best Practice Consensus Guidelines for Intermittent Hemodialysis in Dogs and Cats
Cowgill LD, Langston C, Francey T, et al.
Veterinary Journal. 2024.
60 consensus statements, 12 expert validators (≥75% agreement). First updated veterinary IHD guidelines in decades. Covers AKI, intoxications, and chronic dialysis. Circuit priming volume relative to animal blood volume identified as a critical safety parameter for small patients. Notes HD in experimental dogs since 1913; clinical use ~50 years.
IRISIHDDogs & Cats2024
↗ Vet Journal 2024
#26 Vet Guidelines — IRIS HP 2025
Hemoperfusion for Veterinary Toxicities: IRIS Best Practices Consensus Guidelines
Cowgill LD, Barnes J, Her J, Francey T, et al.
Veterinary Journal. 2025.
First dedicated HP guidelines in veterinary medicine. Evidence base described as "limited, inconsistent, indirect, or of poor quality." HP may be used alone or in-series with HD or TPE. Covers new sorbent device technologies, device-specific recommendations, and monitoring parameters. Explicitly acknowledges rapidly evolving field requiring frequent updates. ≥75% expert consensus required for all statements.
IRISHemoperfusionVet guidelines2025
↗ Vet Journal 2025
#27 Human Guidelines — EXTRIP Framework
EXTRIP Workgroup: Guideline Methodology (AGREE instrument, Delphi consensus)
Lavergne V, Nolin TD, Hoffman RS, et al.
Clinical Toxicology. 2012;50(5):403–413.
Supported by 30+ professional societies. The ECTR clearance threshold criteria (≥30% contribution to total clearance, or significant 6-hour removal) and modified Delphi methodology are the primary frameworks applied in both human and veterinary ECTR guideline development — making this the conceptual foundation for current IRIS vet guidelines.
EXTRIPFramework30+ societies
↗ PubMed: 22578059
Veterinary-specific studies. Includes foundational reviews from 2012–2017 and recent case series/reports from 2019–2025. NSAIDs in dogs are the best-studied indication. No veterinary RCTs exist for EBPT in toxicosis.
Human comparative studies, EXTRIP Workgroup systematic reviews, and technical reviews providing the pharmacokinetic framework and ECTR evidence principles that underpin veterinary EBPT decision-making. Includes toxin-specific EXTRIP recommendations, stepwise clinical decision algorithms, historical HD/HP perspectives, and comprehensive HP technology reviews. The core physicochemical determinants of extracorporeal clearance are species-independent.
IRIS 2024–2025 guidelines represent the current gold standard for veterinary hemodialysis/hemofiltration and hemoperfusion practice. EXTRIP Workgroup methodology provides the evidence-appraisal framework used in both human and veterinary ECTR guideline development.