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Abstract: SA-PO431

Post-Bilateral Orthotopic Lung Transplant Dual Dialysis

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Bhattacharyya, Aniruddha, University of Maryland Medical System, Baltimore, Maryland, United States
  • Zhang, Yani, MedStar Union Memorial Hospital, Baltimore, Maryland, United States
  • Ayele, Girma Moges, Howard University College of Medicine, Washington, District of Columbia, United States

Hyperammonemia (HA) is a metabolic disorder characterized by an elevated concentration of serum ammonia (NH3). It is a complication of Bilateral Orthotopic Lung Transplants (BOLT) befalling 4.1% of patients, with a 75% mortality rate. Opportunistic infections of Ureaplasma are implicated as culprits of HA. Renal replacement therapy (RRT) is the treatment of choice for HA with neurologic symptoms.

NH3 is a small molecule whose clearance mirrors urea in RRT. Intermittent hemodialysis (IHD) clears NH3 faster than continuous hemodialysis (CHD), though CHD is better tolerated in people with hemodynamic instability. There are few studies comparing IHD vs CHD for treating HA in adults.

Case Description

We report a case of a 64-year-old man with new encephalopathy, 1 day after extubation following BOLT. Initial imaging was negative for stroke, and later CT scans showed cerebral edema. Concurrent metabolic workup found an elevated NH3 of 526 umol/L. PCR assays of bronchial fluid after BOLT found the 16S ribosomal RNA sequence of Ureaplasma species.

Soon after developing HA, the patient had hemodynamic instability requiring 3 pressors. While critically ill, we treated his HA with a novel regimen of alternating CHD and IHD. RRT was done via a dialysis catheter placed non-emergently in the right femoral vein.

The CHD was prescribed with a blood flow (QB) of 300ml/min, and a dialysate flow (QD) of 7800ml/h. The first 2 hours of IHD had a QB of 200ml/min, and a QD of 400ml/min. The 2nd and 3rd rounds of IHD had respective QB of 300 and 350ml/min, and respective QD of 500 and 600ml/min. The patient’s NH3 was reduced by 95% over 45 hours by our unique RRT protocol, and he survived this highly fatal condition.


Adult patients after BOLT can develop HA as a rare and deadly complication. Opportunistic infections of urease-producing bacteria like Ureaplasma may play a role in increased NH3 production. While the ideal RRT regimen for HA after BOLT is unknown, our case shows the combination of IHD and CHD can quickly lower NH3 levels and limit its expected rebound in such patients.