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Title: Extracorporeal Ammonia Clearance for Hyperammonemia in Critically Ill Patients: A Scoping Review
Austin Authors: Naorungroj, Thummaporn ;Yanase, Fumitaka ;Eastwood, Glenn M ;Baldwin, Ian C ;Bellomo, Rinaldo 
Affiliation: Intensive Care
Department of Intensive Care, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
Data Analytics Research and Evaluation (DARE) Centre
Issue Date: 4-Dec-2020 2020-12-04
Publication information: Blood Purification 2020; online first: 4 December
Abstract: Introduction: Hyperammonemia is a life-threatening condition. However, clearance of ammonia via extracorporeal treatment has not been systematically evaluated. Methods: We searched EMBASE and MEDLINE databases. We included all publications reporting ammonia clearance by extracorporeal treatment in adult and pediatric patients with clearance estimated by direct dialysate ammonia measurement or calculated by formula. Two reviewers screened and extracted data independently. Results: We found 1,770 articles with 312 appropriate for assessment and 28 studies meeting eligibility criteria. Most of the studies were case reports. Hyperammonemia was typically secondary to inborn errors of metabolisms in children and to liver failure in adult patients. Ammonia clearance was most commonly reported during continuous renal replacement therapy (CRRT) and appeared to vary markedly from <5 mL/min/m2 to >250 mL/min/m2. When measured during intermittent hemodialysis (IHD), clearance was highest and correlated with blood flow rate (R2 = 0.853; p < 0.001). When measured during CRRT, ammonia clearance could be substantial and correlated with effluent flow rate (EFR; R2 = 0.584; p < 0.001). Neither correlated with ammonia reduction. Peritoneal dialysis (PD) achieved minimal clearance, and other extracorporeal techniques were rarely studied. Conclusions: Extracorporeal ammonia clearance varies widely with sometimes implausible values. Treatment modality, blood flow, and EFR, however, appear to affect such clearance with IHD achieving the highest values, PD achieving minimal values, and CRRT achieving substantial values especially at high EFRs. The role of other techniques remains unclear. These findings can help inform practice and future studies.
DOI: 10.1159/000512100
PubMed URL: 33279903
Type: Journal Article
Subjects: Ammonia
Continuous renal replacement therapy
Inborn errors of metabolism
Liver failure
Urea cycle
Type of Clinical Study or Trial: Reviews/Systematic Reviews
Appears in Collections:Journal articles

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