"Why won't the ammonia go down?": ammonia management while on continuous kidney replacement therapy

Area of Science:

• Pediatric Critical Care
• Nephrology
• Metabolic Disorders

Background:

• Kidney replacement therapy (KRT) is vital for critically ill children, often treating hyperammonemia.
• Managing hyperammonemia in pediatric patients not caused by inborn errors of metabolism presents significant challenges.

Purpose of the Study:

• To describe the complex management of hyperammonemia in a critically ill adolescent.
• To highlight the difficulties in optimizing kidney replacement therapy (KRT) for hyperammonemia.
• To emphasize the importance of metabolic support in conjunction with KRT.

Main Methods:

• Case report of a 17-year-old critically ill female with hyperammonemia.
• Initiation and dose escalation of kidney replacement therapy (KRT).
• Reevaluation of metabolic needs, focusing on optimizing glucose delivery and monitoring glucose removal during KRT.

Main Results:

• Despite escalating KRT doses, ammonia levels initially increased.
• Optimizing glucose delivery and monitoring its removal during KRT led to ammonia level stabilization.
• Demonstrated the critical role of metabolic adjustments in KRT management.

Conclusions:

• Effective management of hyperammonemia requires a dynamic interplay between metabolic support and dialysis strategies.
• A glucose delivery calculator is proposed for optimizing treatment.
• Individualized and adaptive approaches are essential for critically ill pediatric patients requiring KRT.