High Anion and High Osmolal Gap Metabolic Acidosis and AKI Requiring CRRT Due to the Coingestion of Gamma-Hydroxybutyrate and Three-Dimensional (3D) Printer Resin

Introduction: We present a case of an individual with persistent high anion gap, high osmolar gap metabolic acidosis, and AKI requiring CRRT after intentional ingestion of multiple substances, including gamma-hydroxybutyrate (GHB), benzodiazepines, and 3D printer resin. This case is unique in its severity, with GHB persisting in the blood at high concentrations much longer than previously described. We also discuss the co ingestion of 3D printer resin, containing methyl acrylates, and it's impact on acidosis. We also review HIV medications known to cause metabolic acidosis and kidney injury, like tenofovir. Case Description: A 33-year old male PMHx of depression, substance use disorder, prior Tenofovir use was found unresponsive after presumed ingestion of GHB, 3D printer resin, and Klonopin. On arrival he was hypothermic (95.7 °F) and hypotensive (94/54 mmHg). Exam with a GCS of 3, intubated for airway protection. Initial labs showed pH 7.23, PCO2 32 mmHg, PO2 100 mmHg, creatinine 0.82 mg/dL, anion gap(AG) 17, and bicarbonate 18 mmol/L. Nine hours later: pH <6.93, PCO2 20 mmHg, PO2 100 mmHg, K 7.3 mmol/L, Cr 1.68 mg/dL, and AG 40, serum osmolality 342 mOsm/kg with an osmolar gap of 51. Despite bicarbonate infusion, acidosis persisted. A GHB level drawn 24 hours post ingestion was 2383.9 µg/mL. CRRT began 13 hours after admission, ran for 24 hours. Acidosis resolved within 8 hours of starting CRRT, kidney function took several days before returning to baseline. Discussion: GHB is a “party drug” with a short half-life that is often co ingested with alcohol and benzodiazepines, making it difficult to obtain accurate incidence and fatality data. Previous reports describe GHB ingestion leading to similar instances of HAGMA with elevated osmolar gap. In all cases, the patient was started on dialysis with improvement within a day. Most GHB samples were sent within hours of ingestion and ranged from 2498–4400 µg/mL, with other case series showing severe symptoms with levels in the 200s. In our unique case, the GHB level 24 hours post ingestion was persistently high, suggesting delayed absorption or impaired clearance, likely from co ingested 3D printer resin or organ dysfunction due to acidosis. This adds to the sparse literature on GHB ingestion. This case also underscores the need for early dialysis in these patients to avoid severe acidosis.