Abstract Theophylline, a drug frequently used to treat apnea of prematurity, has a prolonged half-life of 30 h in neonates. Severe overdoses of theophylline have an asso- ciated 10% mortality and significant morbidity. We de- scribe a 1220-g neonate who developed status epilept- icus due to a theophylline overdose. Hemodialysis was instituted to increase elimination of theophylline. The patient tolerated the procedure without complication. The half-life of theophylline was 0.7 h during dialysis. No reported therapies used in neonates have achieved this magnitude of clearance. In fact, the clearance of the- ophylline in this neonate approached that obtained with hemoperfusion, the standard therapy for theophylline overdose in adult patients. This case demonstrates that hemodialysis is a safe and effective means of enhancing theophylline elimination for neonatal theophylline over- dose. Keywords Hemodialysis · Neonate · Theophylline · Hemoperfusion Introduction Theophylline (1,3-dimethylxanthine) is commonly used to treat neonatal apnea of prematurity. Due to the imma- turity of neonatal cytochrome monooxygenase enzymes, the half-life of theophylline in neonates is 30 h, nine times that in adults [1]. Case reports of theophylline overdoses in neonates [2–4] have described symptoms of overdose that include jitteriness, nausea, vomiting, tachycardia, arrhythmia, seizure and death. Although the mortality and morbidity of theophylline overdose in neonates is unknown, a 10% mortality with significant morbidity has been demonstrated in other age groups [5]. Due to the long half-life of theophylline in neonates, therapies to enhance theophylline clearance in cases of overdose are necessary. Reported treatment modalities to enhance theophylline clearance in neonates have been limited to exchange transfusion [2, 3] and peritoneal dialysis. Single exchange transfusion for theophylline overdose is reported to reduce the half-life from 30 to 28 h [3] and serum concentration by 19% [2]. Peritoneal dialysis decreases theophylline half-life to 14.8 h [6]. Potential additional interventions for enhancing theoph- ylline clearance not reported include multiple dose activated charcoal, hemodialysis and hemoperfusion. Neither exchange transfusion nor peritoneal dialysis provide the degree of theophylline clearance reported in adult patients using these additional interventions. We report on the use of hemodialysis to enhance theoph- ylline clearance in a 1220-g neonate with severe intoxi- cation. Case report The patient was a 1220-g, former 28 week by gestation infant, who presented on the 8th day of life with status epilepticus. Diag- nostic evaluation revealed a theophylline level of 55 mg/l (MEIA using AxSYM analyzer; Abbott Lab., Abbott Park, IL). The neo- nate was prescribed oral theophylline at a dose of 6 mg/kg for loading the day previously. A maintenance dose of 2 mg/kg/ dose every 12 h was then prescribed. He received a single dose 1 h prior to the onset of seizure activity. No explanation for the elevat- ed level could be found after an extensive pharmacy and neonatal intensive care unit investigation. A repeat level 1 h later was 82 mg/l. The increase was thought to be due to absorption of the maintenance dose. Lorazepam and phenobarbital were administered without reso- lution of the seizures. The patient was intubated and placed on J.J. Gitomer ( ✉ ) Department of Nephrology, Marshfield Clinic, 1000 North Oak Ave., Department of Nephrology 3F3, Marshfield, WI 54449, USA e-mail: gitomerj@mfldclin.edu Tel.: +1-715-3875345, Fax: +1-715-3875528 A.M. Khan Department of Pediatrics, University of Texas Medical School, Houston, Texas, USA M.E. Ferris Department of Pediatrics, University of North Carolina at Chapel Hill Medical School, Chapel Hill, NC 27599-7155, USA Pediatr Nephrol (2001) 16:784–786 © IPNA 2001 BRIEF REPORT Jeremy J. Gitomer · Amir M. Khan Maria E. Ferris Treatment of severe theophylline toxicity with hemodialysis in a preterm neonate Received: 12 April 2000 / Revised: 30 April 2001 / Accepted: 2 May 2001