1
|
Duarte T, Fidalgo P, Karvellas CJ, Cardoso FS. What every Intensivist should know about ... Ammonia in liver failure. J Crit Care 2024; 81:154456. [PMID: 37945461 DOI: 10.1016/j.jcrc.2023.154456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/18/2023] [Accepted: 09/12/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) patients have high short-term mortality and morbidity. In the context of liver failure, increased serum ammonia is associated with worse neurological outcomes, including high-grade hepatic encephalopathy (HE), cerebral edema, and intracranial hypertension. Besides its neurotoxicity, hyperammonemia may contribute to immune dysfunction and the risk of infection, a frequent trigger for multi-organ failure in these patients. MATERIAL AND METHODS We performed a literature-based narrative review. Publications available in PubMed® up to June 2023 were considered. RESULTS In the ICU management of liver failure patients, serum ammonia may play an important role. Accordingly, in this review, we focus on recent insights about ammonia metabolism, serum ammonia measurement strategies, hyperammonemia prognostic value, and ammonia-targeted therapeutic strategies. CONCLUSIONS Serum ammonia may have prognostic value in liver failure. Effective ammonia targeted therapeutic strategies are available, such as laxatives, rifaximin, L-ornithine-l-aspartate, and continuous renal replacement therapy.
Collapse
Affiliation(s)
- Tiago Duarte
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
| | - Pedro Fidalgo
- Intensive Care Unit, São Francisco Xavier Hospital, Lisbon, Portugal
| | | | - Filipe S Cardoso
- Transplant Unit, Intensive Care Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal.
| |
Collapse
|
2
|
Dong V, Robinson AM, Dionne JC, Cardoso FS, Rewa OG, Karvellas CJ. Continuous renal replacement therapy and survival in acute liver failure: A systematic review and meta-analysis. J Crit Care 2024; 81:154513. [PMID: 38194760 DOI: 10.1016/j.jcrc.2023.154513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/05/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Acute liver failure (ALF) is a rare syndrome leading to significant morbidity and mortality. An important cause of mortality is cerebral edema due to hyperammonemia. Different therapies for hyperammonemia have been assessed including continuous renal replacement therapy (CRRT). We conducted a systematic review and meta-analysis to determine the efficacy of CRRT in ALF patients. MATERIALS AND METHODS We searched MEDLINE, EMBASE, Cochrane Library, and Web of Science. Inclusion criteria included adult patients admitted to an ICU with ALF. Intervention was the use of CRRT for one or more indications with the comparator being standard care without the use of CRRT. Outcomes of interest were overall survival, transplant-free survival (TFS), mortality and changes in serum ammonia levels. RESULTS In total, 305 patients underwent CRRT while 1137 patients did not receive CRRT. CRRT was associated with improved overall survival [risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70-0.99, p-value 0.04, I2 = 50%] and improved TFS (RR 0.65, 95% CI 0.49-0.85, p-value 0.002, I2 = 25%). There was a trend towards higher mortality with no CRRT (RR 1.24, 95% CI 0.84-1.81, p-value 0.28, I2 = 37%). Ammonia clearance data was unable to be pooled and was not analyzable. CONCLUSION Use of CRRT in ALF patients is associated with improved overall and transplant-free survival compared to no CRRT.
Collapse
Affiliation(s)
- Victor Dong
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada.
| | - Andrea M Robinson
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Joanna C Dionne
- Department of Medicine, Division of Critical Care, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
| | - Filipe S Cardoso
- Intensive Care Unit and Transplant Unit, Nova University, R. da Beneficência 8, Lisbon 1050-099, Portugal.
| | - Oleksa G Rewa
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada; Department of Medicine, Division of Gastroenterology, University of Alberta, 8540 112 St NW, Edmonton, Alberta T6G 2P8, Canada.
| |
Collapse
|
3
|
Lam AH, King JD. Toxin-Induced Liver Injury and Extracorporeal Treatment of Liver Failure. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:157-165. [PMID: 38649220 DOI: 10.1053/j.akdh.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 04/25/2024]
Abstract
Poisoning with a large variety of drugs and naturally occurring toxins may result in acute liver injury and failure. Drug-induced liver injury is a major cause of liver failure nationwide, and it is likely that nephrologists will be involved in treating patients with these conditions. A number of xenobiotics resulting in liver toxicity may cause acute kidney injury or other organ injury as well. Most agents causing drug- or toxin-induced liver failure lack specific therapies, although a few xenobiotics such as acetaminophen have effective antidotal therapies if administered prior to development of hepatotoxicity. The nephrologist should be aware that extracorporeal treatment of liver failure associated with drugs and toxins may be indicated, including therapies conventionally performed by nephrologists (hemodialysis, continuous kidney replacement therapy), therapies occasionally performed by nephrologists and other specialists (plasma exchange, albumin dialysis, hemadsorption), and therapies performed by other specialists (extracorporeal membrane oxygenation). An overview of the role of these therapies in liver failure is provided, as well as a review of their limitations and potential complications.
Collapse
Affiliation(s)
- Angela H Lam
- Maryland Poison Center, Baltimore, MD; Providence St. Joseph Health, Everett, WA; Virginia Mason Franciscan Health, Seattle, WA
| | - Joshua D King
- Maryland Poison Center, Baltimore, MD; Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD.
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW Urea cycle disorders (UCDs) cause elevations in ammonia which, when severe, cause irreversible neurologic injury. Most patients with UCDs are diagnosed as neonates, though mild UCDs can present later - even into adulthood - during windows of high physiologic stress, like critical illness. It is crucial for clinicians to understand when to screen for UCDs and appreciate how to manage these disorders in order to prevent devastating neurologic injury or death. RECENT FINDINGS Hyperammonemia, particularly if severe, causes time- and concentration-dependent neurologic injury. Mild UCDs presenting in adulthood are increasingly recognized, so broader screening in adults is recommended. For patients with UCDs, a comprehensive, multitiered approach to management is needed to prevent progression and irreversible injury. Earlier exogenous clearance is increasingly recognized as an important complement to other therapies. SUMMARY UCDs alter the core pathway for ammonia metabolism. Screening for mild UCDs in adults with unexplained neurologic symptoms can direct care and prevent deterioration. Management of UCDs emphasizes decreasing ongoing ammonia production, avoiding catabolism, and supporting endogenous and exogenous ammonia clearance. Core neuroprotective and supportive critical care supplements this focused therapy.
Collapse
Affiliation(s)
- Micah T Long
- Departments of Anesthesiology & Internal Medicine, University of Wisconsin Hospitals and Clinics
| | - Jacqueline M Kruser
- Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Shane C Quinonez
- Departments of Pediatrics and Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
5
|
Li Y, Yao Z, Li Y, Yang Z, Li M, Chen Z, Liu S, Gong J, Huang L, Xu P, Li Y, Li H, Liu X, Zhang L, Zhang G, Wang H. Prognostic value of serum ammonia in critical patients with non-hepatic disease: A prospective, observational, multicenter study. J Transl Int Med 2023; 11:401-409. [PMID: 38130646 PMCID: PMC10732347 DOI: 10.2478/jtim-2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives Non-hepatic hyperammonemia can damage the central nervous system (CNS), and possible prognostic factors are lacking. This study aimed to investigate the prognostic and risk factors for patients admitted to the intensive care unit (ICU). Materials and Methods This prospective, observational, multicenter study was conducted between November and December 2019 at 11 ICUs in the Chinese Heilongjiang province. Changes in blood ammonia level during and after ICU admission were continuously monitored and expressed as the high level (H-), mean level (M-), and initial level (I-) of ammonia. The risk factors of poor prognosis were investigated by conducting univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive ability of Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE-II) score, lactic acid, total bilirubin (TBil), and M-ammonia. Results A total of 1060 patients were included in this study, of which 707 (67%) had a favorable prognosis and 353 (33%) had a poor prognosis. As shown by univariate models, a poor prognosis was associated with elevated serum levels of lactic acid, TBil, and ammonia (P < 0.05) and pathologic scores from three assessments: APACHE-II, Glasgow Coma Scale (GCS), and Sequential Organ Failure Assessment (SOFA). Multivariate analysis revealed that circulating mean ammonia levels in ICU patients were independently associated with a poor prognosis (odds ratio [OR] = 1.73, 95% confidence interval [CI]: 1.07-2.80, P = 0.02). However, the APACHE-II score (area under the curve [AUC]: 0.714, sensitivity: 0.86, specificity: 0.68, P < 0.001) remained the most predictive factor for patient prognosis by ROC analysis. Conclusion Elevated serum levels of ammonia in the blood were independently prognostic for ICU patients without liver disease.
Collapse
Affiliation(s)
- Yue Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhipeng Yao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Yunlong Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhenyu Yang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Ming Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhendong Chen
- Department of Intensive Care Medicine, The First Affiliated Hospital of Jiamusi University, Jiamusi154004, Heilongjiang Province, China
| | - Shujie Liu
- Department of Intensive Care Medicine, Mudanjiang City Second People’s Hospital, Mudanjiang157199, Heilongjiang Province, China
| | - Jianguo Gong
- Department of Intensive Care Medicine, The Fifth Affiliated Hospital of Harbin Medical University, Daqing163711, Heilongjiang Province, China
| | - Libin Huang
- Department of Intensive Care Medicine, Harbin Fifth Hospital, Harbin150001, Heilongjiang Province, China
| | - Ping Xu
- Department of Intensive Care Medicine, General Hospital of Heilongjiang Province Land Reclamation Bureau, Harbin150001, Heilongjiang Province, China
| | - Yan Li
- Department of Intensive Care Medicine, The First Hospital of Harbin, Harbin150001, Heilongjiang Province, China
| | - Haihong Li
- Department of Intensive Care Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang157000, Heilongjiang Province, China
| | - Xuan Liu
- Department of Intensive Care Medicine, Jiamusi Central Hospital, Jiamusi154003, Heilongjiang Province, China
| | - Li Zhang
- Department of Intensive Care Medicine, Daqing Oilfield General Hospital, Daqing163001, Heilongjiang Province, China
| | - Guixia Zhang
- Department of Intensive Care Medicine, The Longnan Hospital of Daqing, Daqing163458, Heilongjiang Province, China
| | - Hongliang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| |
Collapse
|
6
|
Nelson VL, Stumbras AR, Palumbo RN, Riesgraf SA, Balboa MS, Hannah ZA, Bergstrom IJ, Fecteau CJ, Lake JR, Barry JJ, Ross JJ. Manufacturing and Functional Characterization of Bioengineered Liver Grafts for Extracorporeal Liver Assistance in Acute Liver Failure. Bioengineering (Basel) 2023; 10:1201. [PMID: 37892931 PMCID: PMC10604724 DOI: 10.3390/bioengineering10101201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Acute Liver Failure (ALF) is a life-threatening illness characterized by the rapid onset of abnormal liver biochemistries, coagulopathy, and the development of hepatic encephalopathy. Extracorporeal bioengineered liver (BEL) grafts could offer a bridge therapy to transplant or recovery. The present study describes the manufacture of clinical scale BELs created from decellularized porcine-derived liver extracellular matrix seeded entirely with human cells: human umbilical vein endothelial cells (HUVECs) and primary human liver cells (PHLCs). Decellularized scaffolds seeded entirely with human cells were shown to adhere to stringent sterility and safety guidelines and demonstrated increased functionality when compared to grafts seeded with primary porcine liver cells (PPLCs). BELs with PHLCs were able to clear more ammonia than PPLCs and demonstrated lower perfusion pressures during patency testing. Additionally, to determine the full therapeutic potential of BELs seeded with PHLCs, longer culture periods were assessed to address the logistical constraints associated with manufacturing and transporting a product to a patient. The fully humanized BELs were able to retain their function after cold storage simulating a product transport period. Therefore, this study demonstrates the manufacture of bioengineered liver grafts and their potential in the clinical setting as a treatment for ALF.
Collapse
Affiliation(s)
- Victoria L. Nelson
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Aron R. Stumbras
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - R. Noelle Palumbo
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Shawn A. Riesgraf
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Marie S. Balboa
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Zachary A. Hannah
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Isaac J. Bergstrom
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Christopher J. Fecteau
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - John R. Lake
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
| | - John J. Barry
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| | - Jeff J. Ross
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (A.R.S.); (R.N.P.); (S.A.R.); (M.S.B.); (Z.A.H.); (C.J.F.); (J.R.L.); (J.J.R.)
| |
Collapse
|
7
|
Ocak I. Single-center experience in 127 adult patients, mono or dual artificial liver support therapy, in patients with acute liver failure. Front Med (Lausanne) 2023; 10:1190067. [PMID: 37809330 PMCID: PMC10556512 DOI: 10.3389/fmed.2023.1190067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/12/2023] [Indexed: 10/10/2023] Open
Abstract
Background Acute liver failure (ALF) is a serious condition characterized by sudden liver dysfunction, jaundice and hepatic encephalopathy. Its mortality rate of approximately 80% underscores the urgent need for effective treatments. Supportive extracorporeal therapies (SET), which temporarily support liver function and remove toxins, have shown promise in improving outcomes in acute liver failure (ALF). The aim of this study was to compare the outcomes of dual supportive extracorporeal therapy (SET) and mono supportive extracorporeal therapy in patients with acute liver failure. Methods A total of 127 patients with acute liver failure were included in this retrospective, single-center study. Of these, 62 patients received dual supportive extracorporeal therapy and 65 patients received mono supportive extracorporeal therapy. Primary endpoints were survival without the need for liver transplantation and mortality. Secondary endpoints included resolution of encephalopathy and normalization of International Normalized Ratio (INR). Results In the dual supportive extracorporeal therapy group, 59.6% of patients survived without the need for liver transplantation, while 27.4% achieved recovery with liver transplantation. The mortality rate in this group was 12.9%. Significant regression of encephalopathy grade was observed in 87% of patients, and the 1 year mortality rate for liver transplant recipients was 10.7%. In the mono supportive extracorporeal therapy group, 61.5% of patients experienced a successful recovery without the need for liver transplantation, with a mortality rate of 29.2%. Significant improvement in the grade of encephalopathy was observed in 70.7% of patients. Conclusion Both dual supportive extracorporeal therapy (CVVHDF and PE) and mono supportive extracorporeal therapy (PE) were associated with significant improvements in renal and hepatic biochemical parameters, blood ammonia levels, and neurological status in patients with acute liver failure associated with grade III-IV hepatic encephalopathy. In particular, dual support was associated with improved hemodynamic stability, lactic acidosis and acid-base balance. Survival in acute liver failure in our retrospective cohort using a protocolized approach to extracorporeal therapies is higher compared to previously published large ALF studies. This protocolized approach warrants further prospective studies.
Collapse
|
8
|
Shakerdi L, Ryan A. Drug-induced hyperammonaemia. J Clin Pathol 2023:jcp-2022-208644. [PMID: 37164630 DOI: 10.1136/jcp-2022-208644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
Hyperammonaemia (HA) as a consequence of numerous primary or secondary causes, gives rise to clinical manifestations due to its toxic effects on the brain. The neurological consequences broadly reflect the ammonia level, duration and age, with paediatric patients being more susceptible. Drug-induced HA may arise due to either decreased ammonia elimination or increased production. This is associated most frequently with use of valproate and presents a dilemma between ongoing therapeutic need, toxicity and the possibility of an alternative cause. As there is no specific test for drug-induced HA, prompt discussion with a metabolic physician is recommended, as the neurotoxic effects are time-dependent. Specific guidelines for managing drug-induced HA have yet to be published and hence the treatment approach outlined in this review reflects that outlined in relevant urea cycle disorder guidelines.
Collapse
Affiliation(s)
- Loai Shakerdi
- National Centre for Inherited Metabolic Disorders, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aidan Ryan
- Chemical Pathology, Cork University Hospital Biochemistry Laboratory, Cork, Ireland
- Pathology, University College Cork College of Medicine and Health, Cork, Ireland
| |
Collapse
|
9
|
The cytokine adsorber Cytosorb® does not reduce ammonia concentrations in critically ill patients with liver failure. Intensive Care Med 2023; 49:360-362. [PMID: 36763124 PMCID: PMC9998587 DOI: 10.1007/s00134-023-06998-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
|
10
|
Fisher C, Warrillow S, Bellomo R. Ceremonial purification: which rite is right in liver failure? Intensive Care Med 2023; 49:366. [PMID: 36350355 DOI: 10.1007/s00134-022-06923-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Caleb Fisher
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia. .,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
11
|
Redant S, Warrillow S, Honoré PM. Ammonia and nutritional therapy in the critically ill: when to worry, when to test and how to treat? Curr Opin Clin Nutr Metab Care 2023; 26:160-166. [PMID: 36892962 DOI: 10.1097/mco.0000000000000899] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Hyperammonaemia is almost always develops in patients with severe liver failure and this remains the commonest cause of elevated ammonia concentrations in the ICU. Nonhepatic hyperammonaemia in ICU presents diagnostic and management challenges for treating clinicians. Nutritional and metabolic factors play an important role in the cause and management of these complex disorders. RECENT FINDINGS Nonhepatic hyperammonaemia causes such as drugs, infection and inborn errors of metabolism may be unfamiliar to clinicians and risk being overlooked. Although cirrhotic patients may tolerate marked elevations in ammonia, other causes of acute severe hyperammonaemia may result in fatal cerebral oedema. Any coma of unclear cause should prompt urgent measurement of ammonia and severe elevations warrant immediate protective measures as well as treatments such as renal replacement therapy to avoid life-threatening neurological injury. SUMMARY The current review explores important clinical considerations, the approach to testing and key treatment principles that may prevent progressive neurological damage and improve outcomes for patients with hyperammonaemia, especially from nonhepatic causes.
Collapse
Affiliation(s)
- Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick M Honoré
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Depatment of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
| |
Collapse
|
12
|
Blanchette E, Pahlavan S, Yoeli D, Brigham D, Sater A, Wachs M, Bock M, Adams M. Successful use of intra-operative continuous renal replacement therapy in pediatric liver transplant recipients: Single center case series. Pediatr Transplant 2022; 26:e14377. [PMID: 35959784 DOI: 10.1111/petr.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/09/2022] [Accepted: 07/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in pediatric patients undergoing liver transplantation (LT), with an incidence 17%-55%. Fluid, metabolic, and acid-base aberrancies are often pronounced pre-operatively and further worsened by events during LT, making intra-operative continuous renal replacement therapy (CRRT) an option for critically ill LT recipients. METHODS All pediatric LT performed at our institution who underwent intra-operative CRRT between January 2017 and August 2021 were included. Patient demographics and clinical data including graft outcomes, intra-operative findings, and timing and indications for CRRT were collected from the electronic medical record. RESULTS CRRT was used in nine of the 76 (12%) pediatric LT performed at our center during the study period. Ages at LT ranged from 39 to 17.7 years. Recipients requiring CRRT were more likely to have acute liver failure, status 1A, and higher calculated MELD/PELD scores. CRRT was initiated pre-transplant in three recipients and continued post-transplant in six recipients. Median duration of CRRT was two (range 0-14) days. Indications included hyperammonemia (3/9), acidosis (3/9), fluid overload (6/9), and hyperkalemia (2/9). The CRRT group had a significantly longer post-transplant intensive care unit length of stay in comparison to those that did not require CRRT (median 6, range 3-40 days vs. median 3, range 0-121 days, p = .02], but there were no significant differences in reoperations, hospital length of stay, or recipient or graft survival. CONCLUSIONS We demonstrate that CRRT can be safely performed in pediatric LT recipients, including young infants through adolescents.
Collapse
Affiliation(s)
- Eliza Blanchette
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sheila Pahlavan
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Dor Yoeli
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Dania Brigham
- Division of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Department of Pediatric Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anna Sater
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Wachs
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Center for Transplantation Care, Research and Education (CCTCARE), Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Margret Bock
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Megan Adams
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Center for Transplantation Care, Research and Education (CCTCARE), Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
13
|
Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022. [DOI: 10.1016/j.jcrc.2022.154042
expr 979693480 + 932749582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
|
14
|
Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022; 70:154042. [PMID: 35447602 DOI: 10.1016/j.jcrc.2022.154042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/17/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022]
Abstract
Hyperammonemia occurs frequently in the critically ill but is largely confined to patients with hepatic dysfunction or failure. Non-hepatic hyperammonemia (NHHA) is far less common but can be a harbinger of life-threatening diagnoses that warrant timely identification and, sometimes, empiric therapy to prevent seizures, status epilepticus, cerebral edema, coma and death; in children, permanent cognitive impairment can result. Subsets of patients are at particular risk for developing NHHA, including the organ transplant recipient. Unique etiologies include rare infections, such as with Ureaplasma species, and unmasked inborn errors of metabolism, like urea cycle disorders, must be considered in the critically ill. Early recognition and empiric therapy, including directed therapies towards these rare etiologies, is crucial to prevent catastrophic demise. We review the etiologies of NHHA and highlight the first presentation of it associated with a concurrent Ureaplasma urealyticum and Mycoplasma hominis infection in a previously healthy individual with polytrauma. Based on this clinical review, a diagnostic and treatment algorithm to identify and manage NHHA is proposed.
Collapse
|
15
|
Fisher C, Baldwin I, Fealy N, Naorungroj T, Bellomo R. Ammonia Clearance with Different Continuous Renal Replacement Therapy Techniques in Patients with Liver Failure. Blood Purif 2022; 51:840-846. [PMID: 35042216 DOI: 10.1159/000521312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/02/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) can be used to treat hyperammonaemia. However, no study has assessed the effect of different CRRT techniques on ammonia clearance. METHODS We compared 3 different CRRT techniques in adult patients with hyperammonaemia, liver failure, and acute kidney injury. We protocolized CRRT to progressively deliver continuous veno-venous haemofiltration (CVVH), haemodialysis (CVVHD) or haemodiafiltration (CVVHDF). Ammonia was simultaneously sampled from the patient's arterial blood and effluent fluid for each technique. We applied accepted equations to calculate clearance. RESULTS We studied 12 patients with a median age of 47 years (interquartile range [IQR] 25-79). Acute liver failure was present in 4 (25%) and acute-on-chronic liver failure in 8 (75%). There was no significant difference in median ammonia clearance between CRRT technique; CVVH: 27 (IQR 23-32) mL/min versus CVVHD: 21 (IQR 17-28) mL/min versus CVVHDF: 20 (IQR 14-28) mL/min, p = 0.32. Moreover, for all techniques, ammonia clearance was significantly less than urea and creatinine clearance; urea 50 (47-54) mL/min versus creatinine 42 (IQR 38-46) mL/min versus ammonia 25 (IQR 18-29) mL/min, p = 0.0001. CONCLUSION We found no significant difference in ammonia clearance according to CRRT technique and demonstrated that ammonia clearance is significantly less than urea or creatinine clearance.
Collapse
Affiliation(s)
- Caleb Fisher
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Nigel Fealy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Chris-Olaiya A, Kapoor A, Ricci KS, Lindenmeyer CC. Therapeutic plasma exchange in liver failure. World J Hepatol 2021; 13:904-915. [PMID: 34552697 PMCID: PMC8422921 DOI: 10.4254/wjh.v13.i8.904] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/12/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
The multi-organ failure syndrome associated with acute and acute-on-chronic liver failure (ACLF) is thought to be mediated by overwhelming systemic inflammation triggered by both microbial and non-microbial factors. Therapeutic plasma exchange (TPE) has been proven to be an efficacious therapy in autoimmune conditions and altered immunity, with more recent data supporting its use in the management of liver failure. Few therapies have been shown to improve survival in critically ill patients with liver failure who are not expected to survive until liver transplantation (LT), who are ineligible for LT or who have no access to LT. TPE has been shown to reduce the levels of inflammatory cytokines, modulate adaptive immunity with the potential to lessen the susceptibility to infections, and reduce the levels of albumin-bound and water-bound toxins in liver failure. In patients with acute liver failure, high volume TPE has been shown to reduce the vasopressor requirement and improve survival, particularly in patients not eligible for LT. Standard volume TPE has also been shown to reduce mortality in certain sub-populations of patients with ACLF. TPE may be most favorably employed as a bridge to LT in patients with ACLF. In this review, we discuss the efficacy and technical considerations of TPE in both acute and acute-on-chronic liver failure.
Collapse
Affiliation(s)
| | - Aanchal Kapoor
- Department of Critical Care, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Kristin S Ricci
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Christina C Lindenmeyer
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| |
Collapse
|
17
|
Jeon YH, Kim IY, Jang GS, Song SH, Seong EY, Lee DW, Lee SB, Kim HJ. Clinical outcomes and prognostic factors of mortality in liver cirrhosis patients on continuous renal replacement therapy in two tertiary hospitals in Korea. Kidney Res Clin Pract 2021; 40:687-697. [PMID: 34510860 PMCID: PMC8685364 DOI: 10.23876/j.krcp.21.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/29/2021] [Indexed: 11/04/2022] Open
Abstract
Background Data on liver cirrhosis (LC) patients undergoing continuous renal replacement therapy (CRRT) are lacking despite of the dismal prognosis. We therefore evaluated clinical characteristics and predictive factors related to mortality in LC patients undergoing CRRT. Methods We performed a retrospective observational study at two tertiary hospitals in Korea. A total of 229 LC patients who underwent CRRT were analyzed. Patients were classified into survivor and non-survivor groups. We used multivariable Cox regression analyses to identify predictive factors of in-hospital mortality. Results During a median follow-up of 5 days (interquartile range, 1-19 days), in-hospital mortality rate was 66.4%. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01-1.06; p = 0.02), Model for End-Stage Liver Disease (MELD) score (HR, 1.08; 95% CI, 1.04-1.11; p > 0.001), and delivered CRRT dose (HR, 0.95; 95% CI, 0.92-0.98; p = 0.002) were significant risk factors for in-hospital mortality. Patients with a CRRT delivered dose < 25 mL/kg/hr had a higher mortality rate than those with a delivered dose > 35 mL/kg/hr (HR, 3.13; 95% CI, 1.62-6.05; p = 0.001). Subgroup analysis revealed that a CRRT delivered dose > 25 mL/kg/hr was a significant risk factor for in-hospital mortality among LC patients with a MELD score ≥ 30. Conclusion High APACHE II score, high MELD score, and low delivered CRRT dose were significant risk factors for in-hospital mortality. CRRT delivered dose impacted mortality significantly, especially in patients with a MELD score ≥ 30.
Collapse
Affiliation(s)
- You Hyun Jeon
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Il Young Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Gum Sook Jang
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| |
Collapse
|