Continuous Renal Replacement Therapy with High Flow Rate Can Effectively, Safely, and Quickly Reduce Plasma Ammonia and Leucine Levels in Children

Abstract

Introduction: Peritoneal dialysis and continuous renal replacement therapy (CRRT) are the most frequently used treatment modalities for acute kidney injury. CRRT is currently being used for the treatment of several non-renal indications, such as congenital metabolic diseases. CRRT can efficiently remove toxic metabolites and reverse the neurological symptoms quickly. However, there is not enough data for CRRT in children with metabolic diseases. Therefore, we aimed a retrospective study to describe the use of CRRT in metabolic diseases and its associated efficacy, complications, and outcomes. Materials and Methods: We performed a retrospective analysis of the records of all patients admitted in the pediatric intensive care unit (PICU) for CRRT treatment. Results: Between December 2014 and November 2018, 97 patients were eligible for the present study. The age distribution was between 2 days and 17 years, with a mean of 3.77 ± 4.71 years. There were 13 (36.1%) newborn with metabolic diseases. The patients were divided into two groups: CRRT for metabolic diseases and others. There was a significant relationship between the groups, including age (p ≤ 0.001), weight (p = 0.028), blood flow rate (p ≤ 0.001); dialysate rate (p ≤ 0.001), and replacement rate (p ≤ 0.001). The leucine reduction rate was 3.88 ± 3.65 (% per hour). The ammonia reduction rate was 4.94 ± 5.05 in the urea cycle disorder group and 5.02 ± 4.54 in the organic acidemia group. The overall survival rate was 88.9% in metabolic diseases with CRRT. Conclusion: In particularly hemodynamically unstable patients, CRRT can effectively and quickly reduce plasma ammonia and leucine.

The Effect of dialysis rate on continuous renal replacement therapy for neonatal hyperammonemia

“…Although CRRT is a life-saving treatment, complications such as circuit clotting, hypothermia, hypotension, anemia, thrombocytopenia and electrolyte disturbances may occur during the treatment [22], with anemia and thrombocytopenia being common complications in neonates [23]. In a single-center retrospective study by Akduman [24], the incidence of thrombocytopenia was 62.5%.…”

Characteristics of continuous venovenous hemodiafiltration in the acute treatment of inherited metabolic disorders

“…In recent decades, CKRT has emerged as an essential approach to treating acute metabolic crises in children [ 15 ], and experience in the use of CKRT in infants weighing 10 kg or less has improved [ 16 ]. There have, however, been only a limited number of studies evaluating CKRT in patients diagnosed with IEM to date [ 6 – 8 , 15 ]. The primary strength of the present study is its status as the study with the most extensive CKRT series (28 sessions) in patients diagnosed with IEM to date, and the fact that more than half of the patients (15 patients 53.6%) were under the age of 3 months.…”

“…While there is no current recommended level for starting extracorporeal detoxification for the management of hyperleucinemia, it is known that CKRT may be required if leucine levels exceed 1500 μmol/L [ 17 ]. Aygun et al reported an initial mean leucine level in patients with MSUD of 1777 ± 831.6 μmol/L [ 6 ], while another study reported an initial leucine level of 1648 ± 623.8 μmol/L [ 7 ]. In the present study, the mean initial plasma leucine level value was 1608 ± 885.3 μmol/L, and the initial plasma leucine levels of nine patients were < 1500 μmol/L.…”

“…For instance, a study published in 2019 detected a mean duration of dialysis for hyperammonemia in UCD-diagnosed patients of 46 (33–53) h [ 5 ], while another study reported a mean duration of 19.4 ± 16.4 h in a similar group of patients, and a mean ammonia reduction rate of 5.02 ± 4.53% per hour for patients with organic acidemia [ 6 ]. The same study identified a mean leucine reduction rate of 3.88 ± 3.65%, while Demirkol et al reported a mean leucine reduction rate of between 62.3% and 75.9%, and a mean leucine reduction rate per hour of between 4.5% and 5.8% in different CKRT modalities [ 6 , 7 ]. Moreover, the mean leucine reduction rate and the mean leucine reduction rate per hour were recorded as 83 ± 6.6% and 4 ± 2.5% for CVVHDF, respectively, in another study [ 7 ].…”

Metabolic crisis in maple syrup urine disease: an unusual complication of a rare disease: a case report

“…As the cerebral oedema is due to the neurotoxicity associated with accumulation of the ketoacids and leucine, CVVHDF was commenced on day 3 to assist with clearance of these metabolites. [3][4][5][6][7][8] Nutritional management. The patient's baseline weight (53 kg) and height (1.51 m) were in the normal range (body mass index 23 kg/m 2 ).…”