# Dual Dialysis for Post-bilateral Orthotopic Lung Transplantation Hyperammonemia

## TL;DR

A case study shows that combining two dialysis methods helped treat high ammonia levels in a lung transplant patient.

## Contribution

The novel use of dual dialysis (IHD and CVVHD) in an adult with post-transplant hyperammonemia is presented.

## Key findings

- Combining intermittent and continuous dialysis improved neurological symptoms in a hyperammonemic lung transplant patient.
- Dual dialysis may be a viable treatment for hyperammonemia in adults with hemodynamic instability.
- There is limited literature on hyperammonemia treatment in adult transplant patients.

## Abstract

Hyperammonemia is a metabolic disorder characterized by supraphysiologic ammonia (NH3) concentrations in the blood. Although usually seen in adults with liver disease, hyperammonemia is a notable complication in 4.1% of lung transplants. It is associated with cerebral edema and neurological dysfunction and carries up to 75% mortality in critically ill patients. Opportunistic infections caused by Mycoplasma and Ureaplasma species have been implicated as the cause of this metabolic disturbance. Literature in neonates has shown that renal replacement therapy (RRT) is the best choice for treating patients with neurologic manifestations of hyperammonemia, in cases of NH3 clearance than continuous renal replacement therapy (CRRT). In contrast, continuous venovenous hemodialysis (CVVHD) is usually better tolerated for patients with hemodynamic instability for NH3 clearance. NH3 is a small molecule whose clearance mirrors urea in dialysis. Even though RRT can be a treatment modality for hyperammonemia in adults and neonates, there is very little literature on adults. We present a unique case demonstrating improvement in neurologic manifestations of hyperammonemia by using both IHD and CVVHD in an adult patient.