Intensive Care Medicine

, Volume 39, Issue 7, pp 1227–1237 | Cite as

Clinical impact of arterial ammonia levels in ICU patients with different liver diseases

  • Andreas DrolzEmail author
  • Bernhard Jäger
  • Marlene Wewalka
  • Reinhard Saxa
  • Thomas Horvatits
  • Kevin Roedl
  • Thomas Perkmann
  • Christian Zauner
  • Ludwig Kramer
  • Peter Ferenci
  • Valentin FuhrmannEmail author



Increased arterial ammonia levels are associated with high mortality in patients with acute liver failure (ALF). Data on the prognostic impact of arterial ammonia is lacking in hypoxic hepatitis (HH) and scarce in critically ill patients with cirrhosis.


The patient cohort comprised 72 patients with HH, 43 patients with ALF, 100 patients with liver cirrhosis and 45 patients without evidence for liver disease. Arterial ammonia concentrations were assessed on a daily basis in all patients and the results were compared among these four patient groups and between 28-day survivors and 28-day non-survivors overall and in each group.


Overall 28-day mortality rates in patients with HH, ALF and cirrhosis and in the control group were 54, 30, 49 and 27 %, respectively. Peak arterial ammonia levels differed significantly between transplant-free 28-day survivors and non-survivors in the HH and ALF groups (p < 0.01 for both). Multivariate regression identified peak arterial ammonia concentrations as an independent predictor of 28-day mortality or liver transplantation in patients with HH and ALF, respectively (p < 0.01). There was no association between mortality and arterial ammonia in patients with liver cirrhosis and in the control group. Admission arterial ammonia levels were independently linked to hepatic encephalopathy grades 3/4 in patients with HH (p < 0.01), ALF (p < 0.05) and cirrhosis (p < 0.05), respectively.


Elevated arterial ammonia levels indicate a poor prognosis in acute liver injury and are associated with advanced HE in HH, ALF and cirrhosis. Arterial ammonia levels provide additional information in the risk assessment of critically ill patients with liver disease.


Hypoxic hepatitis Acute liver failure Liver cirrhosis Ammonia Mortality 



Acute liver failure


Area under receiver operating characteristic (ROC) curve


Cardiopulmonary resuscitation


Computed tomography


Hepatic encephalopathy


Hypoxic hepatitis


Intensive care unit


International normalized ratio


Model of end stage liver disease


Systemic inflammatory response syndrome


Simplified acute physiology score II


Sequential organ failure assessment score



No financial support was received for this study.

Conflicts of interest


Supplementary material

134_2013_2926_MOESM1_ESM.doc (48 kb)
Supplementary material 1 (DOC 48 kb)
134_2013_2926_MOESM2_ESM.tiff (10.3 mb)
Supplementary material 2 (TIFF 10541 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • Andreas Drolz
    • 1
    Email author
  • Bernhard Jäger
    • 1
  • Marlene Wewalka
    • 1
  • Reinhard Saxa
    • 1
  • Thomas Horvatits
    • 1
  • Kevin Roedl
    • 1
  • Thomas Perkmann
    • 2
  • Christian Zauner
    • 1
  • Ludwig Kramer
    • 3
  • Peter Ferenci
    • 1
  • Valentin Fuhrmann
    • 1
    Email author
  1. 1.Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III Medical University of ViennaViennaAustria
  2. 2.Department of Laboratory MedicineMedical University of ViennaViennaAustria
  3. 3.Division of Gastroenterology and HepatologyKrankenhaus HietzingViennaAustria

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