Continuous renal replacement therapy and its impact on hyperammonaemia in acute liver failure
Por:
Warrillow, S, Fisher, C, Tibballs, H, Bailey, M, McArthur, C, Lawson-Smith, P, Prasad, B, Anstey, M, Venkatesh, B, Dashwood, G, Walsham, J, Holt, A, Wiersema, U, Gattas, D, Zoeller, M, Alvarez, MG, Bellomo, R
Publicada:
1 jun 2020
Resumen:
Objective: Hyperammonaemia contributes to complications in acute liver failure (ALF) and may be treated with continuous renal replacement therapy (CRRT), but current practice is poorly understood.
Design: We retrospectively analysed data for baseline characteristics, ammonia concentration, CRRT use, and outcomes in a cohort of Australian and New Zealand patients with ALF.
Setting: All liver transplant ICUs across Australia and New Zealand.
Participants: Sixty-two patients with ALF.
Main outcome measures: Impact of CRRT on hyperammonaemia and patient outcomes.
Results: We studied 62 patients with ALF. The median initial (first 24 h) peak ammonia was 132 mu mol/L (interquartile range [IQR], 91-172), median creatinine was 165 mu mol/L (IQR, 92-263) and median urea was 6.9 mmol/L (IQR, 3.1-12.0). Most patients (43/62, 69%) received CRRT within a median of 6 hours (IQR, 2-12) of ICU admission. At CRRT commencement, three-quarters of such patients did not have Stage 3 acute kidney injury (AKI): ten patients (23%) had no KDIGO creatinine criteria for AKI, 12 (28%) only had Stage 1, and ten patients (23%) had Stage 2 AKI. Compared with non-CRRT patients, those treated with CRRT had higher ammonia concentrations (median, 141 mu mol/L [IQR, 102-198] v 91 mu mol/L [IQR, 54-115]; P= 0.02), but a nadir Day 1 pH of only 7.25 (standard deviation, 0.16). Prevention of extreme hyperammonaemia (> 140 mu mol/L) after Day 1 was achieved in 36 of CRRT-treated patients (84%) and was associated with transplant-free survival (55% v 13%; P= 0.05).
Conclusion: In Australian and New Zealand patients with ALF, CRRT is typically started early, before Stage 3 AKI or severe acidaemia, and in the presence hyperammonaemia. In these more severely ill patients, CRRT use was associated with prevention of extreme hyperammonaemia, which in turn, was associated with increased transplant-free survival.
Filiaciones:
Warrillow, S:
Austin Hlth, Dept Intens Care, Melbourne, Vic, Australia
Univ Melbourne, Melbourne, Vic, Australia
Fisher, C:
Austin Hlth, Dept Intens Care, Melbourne, Vic, Australia
Tibballs, H:
Austin Hlth, Dept Intens Care, Melbourne, Vic, Australia
Bailey, M:
Univ Melbourne, Melbourne, Vic, Australia
Monash Univ, Australian & New Zealand Intens Care Res Ctr, Sch Publ Hlth & Prevent Med, Melbourne, Vic, Australia
McArthur, C:
Med Res Inst New Zealand, Auckland, New Zealand
Auckland City Hosp, Dept Crit Care Med, Auckland, New Zealand
Lawson-Smith, P:
Auckland City Hosp, Dept Crit Care Med, Auckland, New Zealand
Prasad, B:
South Metropolitan Hlth Serv, Perth, WA, Australia
Anstey, M:
Sir Charles Gairdner Hosp, Dept Intens Care, Perth, WA, Australia
Venkatesh, B:
Princess Alexandra Hosp, Dept Intens Care, Brisbane, Qld, Australia
Dashwood, G:
Princess Alexandra Hosp, Dept Intens Care, Brisbane, Qld, Australia
Walsham, J:
Princess Alexandra Hosp, Dept Intens Care, Brisbane, Qld, Australia
Holt, A:
Flinders Med Ctr, Dept Intens Care, Adelaide, SA, Australia
Wiersema, U:
Flinders Med Ctr, Dept Intens Care, Adelaide, SA, Australia
Gattas, D:
Royal Prince Alfred Hosp, Dept Intens Care, Sydney, NSW, Australia
Zoeller, M:
Royal Prince Alfred Hosp, Dept Intens Care, Sydney, NSW, Australia
Alvarez, MG:
Univ Barcelona, Dept Anaesthesiol & Pain Med, Hosp Santa Creu & St Pau, Barcelona, Spain
Bellomo, R:
Austin Hlth, Dept Intens Care, Melbourne, Vic, Australia
Univ Melbourne, Melbourne, Vic, Australia
Royal Melbourne Hosp, Dept Intens Care, Melbourne, Vic, Australia
Austin Hosp, Data Analyt Res & Evaluat DARE Ctr, Melbourne, Vic, Australia
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