"Why won't the ammonia go down?": ammonia management while on continuous kidney replacement therapy.

Background: Kidney replacement therapy (KRT) is commonly used to treat critically ill children for a variety of reasons, including hyperammonemia. KRT management in children with hyperammonemia not due to inborn errors of metabolism is challenging.

Case presentation: We report a complex case of hyperammonemia in a 17-year-old critically ill female patient, emphasizing the challenges of management in a pediatric intensive care setting. Despite the initiation of kidney replacement therapy (KRT) and progressive increases in the prescribed dialytic dose, the patient's ammonia levels continued to escalate. This prompted a reevaluation of her metabolic needs, with a focus on optimizing glucose delivery to facilitate ammonia metabolism and dialytic clearance. Adjustments to increase the delivered glucose, along with careful monitoring of glucose removal during KRT, ultimately led to the stabilization of her ammonia levels.

Conclusion: This case underscores the intricate interplay between metabolic support and dialytic strategies in the management of hyperammonemia. The use of a glucose delivery calculator is proposed. This case highlights the need for individualized, dynamic approaches in critically ill pediatric patients.