Hyperammonemia has been associated with intracranial hypertension and mortality in patients with acute liver failure (ALF). We evaluated the effect of renal replacement therapy (RRT) on serum ammonia level and outcomes in ALF. This was a multicenter cohort study of consecutive ALF patients from the United States ALF Study Group registry between January 1998 and December 2016. First, we studied the association of ammonia with hepatic encephalopathy (HE) and 21‐day transplant‐free survival (TFS; n = 1,186). Second, we studied the effect of RRT on ammonia for the first 3 days post study admission (n = 340) and on 21‐day TFS (n = 1,186). Higher admission (n = 1,186) median ammonia level was associated with grade 3‐4 HE (116 vs. 83 μmol/L) and mortality at day 21 attributed to neurological (181 vs. 90 μmol/L) and all causes (114 vs. 83 μmol/L; P < 0.001 for all). Among 340 patients with serial ammonia levels, 61 (18%) were on continuous RRT (CRRT), 59 (17%) were on intermittent RRT (IRRT), and 220 (65%) received no RRT for the first 2 days. From days 1 to 3, median ammonia decreased by 38%, 23%, and 19% with CRRT, IRRT, and no RRT, respectively. Comparing to no RRT use, whereas ammonia reduction with CRRT was significant (P = 0.007), with IRRT it was not (P = 0.75). After adjusting for year of enrollment, age, etiology, and disease severity, whereas CRRT (odds ratio [OR], 0.47 [95% confidence interval {CI}, 0.26‐0.82]) was associated with reduction in 21‐day transplant‐free all‐cause mortality, IRRT (OR, 1.68 [95% CI, 1.04‐2.72]) was associated with an increase. Conclusion: In a large cohort of ALF patients, hyperammonemia was associated with high‐grade HE and worse 21‐day TFS. CRRT was associated with a reduction in serum ammonia level and improvement of 21‐day TFS. (Hepatology 2018;67:711‐720).

中文翻译：

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连续肾脏替代治疗与急性肝衰竭患者血清氨水平和死亡率降低有关

高氨血症与急性肝衰竭 (ALF) 患者的颅内高压和死亡率有关。我们评估了肾脏替代疗法 (RRT) 对 ALF 血清氨水平和结局的影响。这是 1998 年 1 月至 2016 年 12 月期间美国 ALF 研究组登记处连续 ALF 患者的多中心队列研究。首先，我们研究了氨与肝性脑病 (HE) 和 21 天无移植生存率 (TFS; n = 1,186）。其次，我们研究了 RRT 对入院后前 3 天（n = 340）和 21 天 TFS（n = 1,186）的氨的影响。较高的入院 (n = 1,186) 中位氨水平与 3-4 级 HE（116 对 83 μmol/L）和第 21 天归因于神经系统疾病（181 对 90 μmol/L）和所有原因（114 对 83 μmol/L）的死亡率相关. 83 μmol/L；P < 0。001 为所有）。在具有连续氨水平的 340 名患者中，61 (18%) 名接受连续 RRT (CRRT)，59 (17%) 名接受间歇性 RRT (IRRT)，220 (65%) 名在前 2 天未接受 RRT。从第 1 天到第 3 天，使用 CRRT、IRRT 和不使用 RRT 的氨中位数分别下降了 38%、23% 和 19%。与不使用 RRT 相比，CRRT 的氨减少显着（P = 0.007），而 IRRT 则不是（P = 0.75）。在调整入组年份、年龄、病因和疾病严重程度后，而 CRRT（优势比 [OR]，0.47 [95% 置信区间 {CI}，0.26-0.82]）与 21 天无移植IRRT (OR, 1.68 [95% CI, 1.04-2.72]) 与全因死亡率的增加有关。结论：在一大群 ALF 患者中，高氨血症与高级别 HE 和更差的 21 天 TFS 相关。CRRT 与血清氨水平降低和 21 天 TFS 改善相关。（肝病学 2018 年；67：711-720）。