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Hyperammonemia in lung transplant patients and its management: a review

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Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Objective

To synthesize the evidence for incidence, pathophysiology, etiology, and protocol-based management of hyperammonemia in lung transplant patients.

Background

Elevated ammonia levels are toxic to the brain, and hyperammonemia results in a potentially fatal complication for lung transplant recipients. The hallmark of this condition is ammonia production being way out of proportion to the degree of liver derangement. While there are many hypotheses, the cause remains obscure.

Methods

A retrospective review of patients with hyperammonemia following lung transplantation was done to understand the pathophysiology, various treatment modalities, and its impact on patient mortality and morbidity. Studies in the English literature were identified through an electronic database search from PubMed/MEDLINE, Ovid Embase, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Web of Science, and ClinicalTrials.gov until June 2020. No restriction of dates were used, and the search was up until June 2020.

Discussion

Mortality among patients with hyperammonemia following lung transplantation is high. Multi-modal treatment approaches include avoiding nephrotoxic drugs, use of bowel decontamination, nitrogen scavengers, branched-chain amino acids, adjustment of immunosuppression, antibiotics like fluoroquinolones or azithromycin, and renal replacement therapy. However, there remains a scarcity of preoperative screening protocol for patients at risk of hyperammonemia as well evidence-based post-operative management guidelines. Intermittent hemodialysis, compared to continuous venovenous hemodialysis, provides better patient outcomes.

Conclusion

Early detection of patients at risk by appropriate screening, along with maintaining a high degree of suspicion for hyperammonemia and multi-modal treatment approach, is the key to successful patient outcomes. Further prospective observational studies would facilitate development of protocol-based treatment of this potentially fatal condition.

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Acknowledgements

We would like to thank Elsevier, the publishers of American Journal of Neuroradiology, for granting us the permission to republish the MRI scan images (Fig. 3) for review purposes.

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Authors and Affiliations

  1. Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 100 Lothrop St, Pittsburgh, PA, 15213, USA

    Akshay Kumar

  2. Department of Cardiothoracic Surgery, Medanta Hospital, Gurugram, India

    Akshay Kumar

  3. Terasaki Institute of Biomedical Innovation, Los Angeles, CA, USA

    Shailesh Advani

  4. Department of Internal Medicine, Central Michigan University, Michigan, MI, USA

    Kichloo Asim, Mohamed A. Mohamed & Farah Wani

  5. Department of Nephrology, Guthrie Robert Packer Hospital, Sayre, PA, USA

    Jagmeet Singh

  6. Department of Internal Medicine, University of Miami Hospital, Miami, FL, USA

    Michael Albosta

  7. Department of Anesthesiology, University of Texas Health Center, Houston, TX, USA

    Nimisha Shiwalkar

  8. Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY, USA

    Suresh Keshavamurthy

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  1. Akshay Kumar
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Correspondence to Akshay Kumar.

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Kumar, A., Advani, S., Asim, K. et al. Hyperammonemia in lung transplant patients and its management: a review. Indian J Thorac Cardiovasc Surg 38 (Suppl 2), 335–346 (2022). https://doi.org/10.1007/s12055-021-01319-6

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  • DOI: https://doi.org/10.1007/s12055-021-01319-6

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