# “Why won’t the ammonia go down?”: ammonia management while on continuous kidney replacement therapy

## TL;DR

This paper discusses the challenges of managing high ammonia levels in a critically ill teenager undergoing kidney therapy and highlights the importance of balancing metabolic support and dialysis.

## Contribution

The paper proposes a glucose delivery calculator to guide ammonia management in pediatric patients on kidney replacement therapy.

## Key findings

- Ammonia levels continued to rise despite increased dialytic doses in a critically ill pediatric patient.
- Optimizing glucose delivery and monitoring glucose removal helped stabilize ammonia levels.
- The case emphasizes the need for individualized and dynamic approaches in managing hyperammonemia.

## Abstract

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.

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.

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.

The online version contains supplementary material available at 10.1007/s00467-025-07006-7.