Ammonia clearance with haemofiltration in adults with liver disease

Andrew J. Slack; Georg Auzinger; Chris Willars; Tracy Dew; Rebecca Musto; Daniel Corsilli; Roy Sherwood; Julia A. Wendon; William Bernal

doi:10.1111/liv.12221

Ammonia clearance with haemofiltration in adults with liver disease

Andrew J. Slack, Georg Auzinger, Chris Willars, Tracy Dew, Rebecca Musto, Daniel Corsilli, Roy Sherwood, Julia A. Wendon, William Bernal^*

^*Corresponding author for this work

KCH King's College Hospital NHS Foundation Trust

Research output: Contribution to journal › Article › peer-review

140 Citations (Scopus)

Abstract

Background & Aims: Ammonia is recognized as a toxin central to complications of liver failure. Hyperammonaemia has important clinical consequences, but optimal means to reduce circulating levels are uncertain. In patients with liver disease, continuous renal replacement therapy (CRRT) with haemofiltration (HF) is often required to treat concurrent kidney injury, but its effects upon ammonia levels are poorly characterized. To evaluate the effect of HF at different treatment intensities on ammonia clearance (AC) and arterial ammonia concentration. Methods: Prospective study of adult patients with liver failure and arterial ammonia >100 μmol/L requiring CRRT using veno-venous HF. Arterial ammonia concentration and AC measured at 1 and 24 h after initiation of low (35 ml/kg/h) or high (90 ml/kg/h) filtration volume. Results: Twenty-four patients (10 acute liver failure, 10 chronic liver disease and 4 following liver resection) were studied. Clearance of urea and ammonia solutes correlated closely (r = 0.819, P = 0.007). Ammonia clearance correlated closely with ultrafiltration rate (r = 0.86, P < 0.001). At 1 h, AC was 39 (34–54) ml/min (low volume) vs 85 (62–105) ml/min (high volume) CRRT, (P < 0.001) and at 24 h 44 (34–63) vs 105 (82–109) ml/min, (P = 0.01). Overall, a 22% reduction in median arterial ammonia concentration was observed over 24 h of HF from 156 (137–176) to 122 (85–133) μmol/L, (P ≤ 0.0001). Conclusion: Clinically significant ammonia clearance can be achieved in adult patients with hyperammonaemia utilizing continuous VVHF. Ammonia clearance is closely correlated with ultrafiltration rate. HF was associated with a fall in arterial ammonia concentration.

Original language	English
Pages (from-to)	42-48
Number of pages	7
Journal	LIVER INTERNATIONAL
Volume	34
Issue number	1
DOIs	https://doi.org/10.1111/liv.12221
Publication status	Published - Jan 2014

Keywords

ammonia clearance
Cordoba equation
haemofiltration
hyperammonaemia
ultrafiltration rate
HIGH-VOLUME HEMOFILTRATION
RENAL-REPLACEMENT THERAPY
CRITICALLY-ILL PATIENTS
HEPATIC-ENCEPHALOPATHY
ARTERIAL AMMONIA
SEPTIC SHOCK
INTRACRANIAL HYPERTENSION
ACUTE MANAGEMENT
INBORN-ERRORS
DOUBLE-BLIND

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10.1111/liv.12221

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@article{b0739605951c4b0da72077306c1801e8,

title = "Ammonia clearance with haemofiltration in adults with liver disease",

abstract = "Background & Aims: Ammonia is recognized as a toxin central to complications of liver failure. Hyperammonaemia has important clinical consequences, but optimal means to reduce circulating levels are uncertain. In patients with liver disease, continuous renal replacement therapy (CRRT) with haemofiltration (HF) is often required to treat concurrent kidney injury, but its effects upon ammonia levels are poorly characterized. To evaluate the effect of HF at different treatment intensities on ammonia clearance (AC) and arterial ammonia concentration. Methods: Prospective study of adult patients with liver failure and arterial ammonia >100 μmol/L requiring CRRT using veno-venous HF. Arterial ammonia concentration and AC measured at 1 and 24 h after initiation of low (35 ml/kg/h) or high (90 ml/kg/h) filtration volume. Results: Twenty-four patients (10 acute liver failure, 10 chronic liver disease and 4 following liver resection) were studied. Clearance of urea and ammonia solutes correlated closely (r = 0.819, P = 0.007). Ammonia clearance correlated closely with ultrafiltration rate (r = 0.86, P < 0.001). At 1 h, AC was 39 (34–54) ml/min (low volume) vs 85 (62–105) ml/min (high volume) CRRT, (P < 0.001) and at 24 h 44 (34–63) vs 105 (82–109) ml/min, (P = 0.01). Overall, a 22% reduction in median arterial ammonia concentration was observed over 24 h of HF from 156 (137–176) to 122 (85–133) μmol/L, (P ≤ 0.0001). Conclusion: Clinically significant ammonia clearance can be achieved in adult patients with hyperammonaemia utilizing continuous VVHF. Ammonia clearance is closely correlated with ultrafiltration rate. HF was associated with a fall in arterial ammonia concentration.",

keywords = "ammonia clearance, Cordoba equation, haemofiltration, hyperammonaemia, ultrafiltration rate, HIGH-VOLUME HEMOFILTRATION, RENAL-REPLACEMENT THERAPY, CRITICALLY-ILL PATIENTS, HEPATIC-ENCEPHALOPATHY, ARTERIAL AMMONIA, SEPTIC SHOCK, INTRACRANIAL HYPERTENSION, ACUTE MANAGEMENT, INBORN-ERRORS, DOUBLE-BLIND",

author = "Slack, {Andrew J.} and Georg Auzinger and Chris Willars and Tracy Dew and Rebecca Musto and Daniel Corsilli and Roy Sherwood and Wendon, {Julia A.} and William Bernal",

year = "2014",

month = jan,

doi = "10.1111/liv.12221",

language = "English",

volume = "34",

pages = "42--48",

journal = "LIVER INTERNATIONAL",

issn = "1478-3223",

publisher = "Wiley-Blackwell",

number = "1",

}

TY - JOUR

T1 - Ammonia clearance with haemofiltration in adults with liver disease

AU - Slack, Andrew J.

AU - Auzinger, Georg

AU - Willars, Chris

AU - Dew, Tracy

AU - Musto, Rebecca

AU - Corsilli, Daniel

AU - Sherwood, Roy

AU - Wendon, Julia A.

AU - Bernal, William

PY - 2014/1

Y1 - 2014/1

N2 - Background & Aims: Ammonia is recognized as a toxin central to complications of liver failure. Hyperammonaemia has important clinical consequences, but optimal means to reduce circulating levels are uncertain. In patients with liver disease, continuous renal replacement therapy (CRRT) with haemofiltration (HF) is often required to treat concurrent kidney injury, but its effects upon ammonia levels are poorly characterized. To evaluate the effect of HF at different treatment intensities on ammonia clearance (AC) and arterial ammonia concentration. Methods: Prospective study of adult patients with liver failure and arterial ammonia >100 μmol/L requiring CRRT using veno-venous HF. Arterial ammonia concentration and AC measured at 1 and 24 h after initiation of low (35 ml/kg/h) or high (90 ml/kg/h) filtration volume. Results: Twenty-four patients (10 acute liver failure, 10 chronic liver disease and 4 following liver resection) were studied. Clearance of urea and ammonia solutes correlated closely (r = 0.819, P = 0.007). Ammonia clearance correlated closely with ultrafiltration rate (r = 0.86, P < 0.001). At 1 h, AC was 39 (34–54) ml/min (low volume) vs 85 (62–105) ml/min (high volume) CRRT, (P < 0.001) and at 24 h 44 (34–63) vs 105 (82–109) ml/min, (P = 0.01). Overall, a 22% reduction in median arterial ammonia concentration was observed over 24 h of HF from 156 (137–176) to 122 (85–133) μmol/L, (P ≤ 0.0001). Conclusion: Clinically significant ammonia clearance can be achieved in adult patients with hyperammonaemia utilizing continuous VVHF. Ammonia clearance is closely correlated with ultrafiltration rate. HF was associated with a fall in arterial ammonia concentration.

AB - Background & Aims: Ammonia is recognized as a toxin central to complications of liver failure. Hyperammonaemia has important clinical consequences, but optimal means to reduce circulating levels are uncertain. In patients with liver disease, continuous renal replacement therapy (CRRT) with haemofiltration (HF) is often required to treat concurrent kidney injury, but its effects upon ammonia levels are poorly characterized. To evaluate the effect of HF at different treatment intensities on ammonia clearance (AC) and arterial ammonia concentration. Methods: Prospective study of adult patients with liver failure and arterial ammonia >100 μmol/L requiring CRRT using veno-venous HF. Arterial ammonia concentration and AC measured at 1 and 24 h after initiation of low (35 ml/kg/h) or high (90 ml/kg/h) filtration volume. Results: Twenty-four patients (10 acute liver failure, 10 chronic liver disease and 4 following liver resection) were studied. Clearance of urea and ammonia solutes correlated closely (r = 0.819, P = 0.007). Ammonia clearance correlated closely with ultrafiltration rate (r = 0.86, P < 0.001). At 1 h, AC was 39 (34–54) ml/min (low volume) vs 85 (62–105) ml/min (high volume) CRRT, (P < 0.001) and at 24 h 44 (34–63) vs 105 (82–109) ml/min, (P = 0.01). Overall, a 22% reduction in median arterial ammonia concentration was observed over 24 h of HF from 156 (137–176) to 122 (85–133) μmol/L, (P ≤ 0.0001). Conclusion: Clinically significant ammonia clearance can be achieved in adult patients with hyperammonaemia utilizing continuous VVHF. Ammonia clearance is closely correlated with ultrafiltration rate. HF was associated with a fall in arterial ammonia concentration.

KW - ammonia clearance

KW - Cordoba equation

KW - haemofiltration

KW - hyperammonaemia

KW - ultrafiltration rate

KW - HIGH-VOLUME HEMOFILTRATION

KW - RENAL-REPLACEMENT THERAPY

KW - CRITICALLY-ILL PATIENTS

KW - HEPATIC-ENCEPHALOPATHY

KW - ARTERIAL AMMONIA

KW - SEPTIC SHOCK

KW - INTRACRANIAL HYPERTENSION

KW - ACUTE MANAGEMENT

KW - INBORN-ERRORS

KW - DOUBLE-BLIND

U2 - 10.1111/liv.12221

DO - 10.1111/liv.12221

M3 - Article

SN - 1478-3223

VL - 34

SP - 42

EP - 48

JO - LIVER INTERNATIONAL

JF - LIVER INTERNATIONAL

IS - 1

ER -

Ammonia clearance with haemofiltration in adults with liver disease

Abstract

Keywords

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