Abstract: SA-PO435
Different Modalities of Dialysis for Hyperammonemia Treatment
Session Information
- Hemodialysis and Frequent Dialysis: Clearance, Technology, Infection
November 05, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 701 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Sbaih, Ahmed S.H., Tulane University School of Medicine, New Orleans, Louisiana, United States
- Sharshir, Moh'd, Tulane University School of Medicine, New Orleans, Louisiana, United States
- Harasis, Farah, Islamic Hospital, Amman, Amman, Jordan
Introduction
Hyperammonemia (HA) is a life-threatening condition and can lead to irreversible cerebral damage and death if not treated in a proper way. A Few studies found in literature about the treatment of HA by dialysis in adults. Here, we describe a two cases of acute encephalopathy due HA with different causes. Treated successfully with different modalities of dialysis.
Case Description
Case 1: A 23-year-old female presented with altered mental status. Laboratory workups showed ammonia level of 581 (reference value 11 -32) micromol/l with normal lactate, creatinine, and liver enzymes. Brain image showed a cerebral edema. Urea cycle disorder was suspected. Along with medical treatment, Dialysis was initiated using Sustained low efficiency dialysis for 48 hours, Ammonia level decreased to 74. She completely recovered after that and did not need dialysis, ammonia level returned to normal level and discharged without neurological deficit.
Case 2: A 67-year-old female with liver cirrhosis presented with altered mental status and gastrointestinal bleeding. Laboratory data revealed ammonia level of 263. Intermittent hemodialysis (iHD) was performed for 3 hours then switch to Continuous venovenous hemofiltration (CVVHD) for 24 hours. Level returned to normal, and patient improved then discharged without neurological deficit.
Discussion
HA can occur in patients with liver failure, urea cycle defects, inborn errors of metabolism (IEM), post-chemotherapy, toxins exposure or drugs. Management should be started immediately to avoid life threatening consequences. However, there are no specific guidelines about when to start dialysis or which techniques are more appropriate. Generally, the primary goals of dialysis are to rapidly reduce ammonia level and achieve resolution of symptoms. It has been proposed that, when the blood ammonia level is three times greater than the upper limit of normal or encephalopathy, it is worth considering dialysis. Among adult patients, the goal to provide continuous removal of ammonia by performing daily HD and CVVH in between sessions of HD to prevent ammonia rebound as what we did in the second case. If cerebral edema is present as in the first case, we would elect a continuous technique (CVVHD or SLED) to avoid worsening the edema with iHD.