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Kidney Week

Abstract: TH-PO777

Renal Replacement Therapy of Hyperammonaemia in Pediatric Patients

Session Information

  • Pediatric CKD
    November 07, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Pediatric Nephrology

  • 1700 Pediatric Nephrology

Authors

  • Radhakrishnan, Yeshwanter, Akron General Medical Centre, Akron, Ohio, United States
  • Raina, Rupesh, Cleveland Clinic Akron General, Akron, Ohio, United States
Background

Hyperammonemia is the accumulation of ammonia in the blood that may result in an acute life-threatening event in pediatric populations. Management of hyperammonemia proves to be difficult in pediatric populations given the non-specific clinical symptoms, the age-specific etiologies, and the lack of consensus in the treatment plan. In our review, we sought to systematically search the published literature to comprise guidelines for non-renal replacement therapy (RRT) and renal replacement therapy in pediatric patients.

Methods

A database search using PubMed/Medline, Embase and Cochrane was performed to include publications about hyperammonemia and renal replacement therapy in the pediatric population. An expert panel of pediatric nephrologists made up the workgroup and they were responsible to review and propose recommendations for renal replacement therapy guidelines for hyperammonemia children.

Results

The initial search returned a total of 477 citations of which only 25 studies met our inclusion criteria. A total of 132 patients were included in the study. Hemodialysis indications included hyperammonemia refractory to medical management and hyperammonemia coma. The most common of hyperammonemia was inborn errors of metabolism (IEM). Among the type of RRT used, CRRT had a 60% success rate and peritoneal dialysis (PD) had a 65% success rate

Conclusion

We recommend initiating renal replacement therapy when blood ammonia levels >150μmol/L with coma or cerebral edema and when blood ammonia level > 400μmol/L refractory to non-RRT measures. Intermittent hemodialysis is more effective than PD or CRRT as it clears ammonia faster but associated with rebound hyperammonemia and can cause hypotension and rapid osmotic shifts. PD is a quick alternative to immediate hyperammonemia management if CRRT is not available. Treating with high dose-CRRT allows for rapid clearance of ammonia done on a single dialysis run. A hybrid method of CRRT with ECMO support can increase the patient's blood volumes, allows for use of a larger cannula, avoids hemodynamic instability.