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High-dose continuous renal replacement therapy for neonatal hyperammonemia

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Abstract

Background

Infants with hyperammonemia can present with nonspecific findings so ordering an ammonia level requires a high index of suspicion. Renal replacement therapy (RRT) should be considered for ammonia concentrations of >400 μmol/L since medical therapy will not rapidly clear ammonia. However, the optimal RRT prescription for neonatal hyperammonemia remains unknown. Hemodialysis and continuous renal replacement therapy (CRRT) are both effective, with differing risks and benefits.

Case-diagnosis/treatment

We present the cases of two neonates with hyperammonemia who were later diagnosed with ornithine transcarbamylase deficiency and received high-dose CRRT. Using dialysis/replacement flow rates of 8,000 mL/h/1.73 m2 (1,000 mL/h or fourfold higher than the typical rate used for acute kidney injury) the ammonia decreased to <400 μmol/L within 3 h of initiating CRRT and to <100 μmol/L within 10 h.

Conclusions

We propose a CRRT treatment algorithm to rapidly decrease the ammonia level using collaboration between the emergency department and departments of genetics, critical care, surgery/interventional radiology, and nephrology.

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Acknowledgments

We thank Kimberly Windt, RN for providing outstanding care to our patient. Dr. BL Laskin is supported by a Career Development grant in Comparative Effectiveness Research (1KM1CA156715-01).

Conflict of interest

Dr. Stuart Goldstein is currently a consultant and expert panel member for Gambro and has received grant support from Gambro. He is also a consultant for Baxter and has received grant support from Baxter. These sponsors played no role in the study design, collection, analysis, and interpretation of data, writing of the report, or the decision to submit the paper for publication.

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Authors and Affiliations

  1. Division of Nephrology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA

    Joann M. Spinale & Benjamin L. Laskin

  2. Division of Child Rehabilitation and Biochemical Genetics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Neal Sondheimer

  3. Renal Services, Department of Pediatrics, Baylor College of Medicine–Texas Children’s Hospital, Houston, TX, USA

    Sarah J. Swartz

  4. Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Stuart L. Goldstein

Authors
  1. Joann M. Spinale
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  2. Benjamin L. Laskin
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  3. Neal Sondheimer
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  4. Sarah J. Swartz
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  5. Stuart L. Goldstein
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Corresponding author

Correspondence to Joann M. Spinale.

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Spinale, J.M., Laskin, B.L., Sondheimer, N. et al. High-dose continuous renal replacement therapy for neonatal hyperammonemia. Pediatr Nephrol 28, 983–986 (2013). https://doi.org/10.1007/s00467-013-2441-8

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  • DOI: https://doi.org/10.1007/s00467-013-2441-8

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