Original Research

Role of Sustained Low-Efficiency Dialysis (SLED) in HyperammoniaPatients with Hepatic Encephalopathy

Saleem Sharieff
Pakistan Kidney and Liver Institute and Research Centre (PKLI-RC), Lahore, Pakistan
Wajid Ali Rafai
Pakistan Kidney and Liver Institute and Research Centre (PKLI-RC), Lahore, Pakistan
Adil Manzoor
Pakistan Kidney and Liver Institute and Research Centre (PKLI-RC), Lahore, Pakistan
Ahsen Asad
Pakistan Kidney and Liver Institute and Research Centre (PKLI-RC), Lahore, Pakistan
Mahrukh Gulraiz
Pakistan Kidney and Liver Institute and Research Centre (PKLI-RC), Lahore, Pakistan
Hamna Sawaiba Rai
Pakistan Kidney and Liver Institute and Research Centre (PKLI-RC), Lahore, Pakistan

✉ Correspondence: Saleem Sharieff Email: ssharieff@live.ca

DOI https://doi.org/10.70302/jpsim.v6i1.2514
Volume: 6, Issue 1 Pages: 65–70 Published: 10 Mar 2025
Received: 30 Apr 2024 Revised: 30 Jan 2025 Accepted: 22 Feb 2025 Published Online: 10 Mar 2025

Abstract

Objective

To observe sustained low-efficiency dialysis (SLED) in patients with hyperammonia secondary to liver failure.

Methods

In this retrospective study, 20 patients with hepatic encephalopathy from hyperammonia secondary to liver failure (14 with ACLF and 6 with ALF) were offered SLED. The study excluded pediatric patients and those with normal ammonia or without hepatic encephalopathy. Data collected included demographics, diagnosis, lab results, APACHE II/SOFA scores, and outcomes. Ammonia levels were monitored before and during SLED. Success was defined by ammonia reduction and clinical improvement.
The SLED protocol used a 300 mL/min dialysate flow, 100–200 mL/min blood flow, and ultrafiltration of 0–2500 mL/session for 6–8 hours daily. SLED was stopped when ammonia remained <145 μg/dL (85 μmol/L) twice, 12–24 hours apart, with neurological improvement.

Results

The mean age was 41 ± 14.5. A total of 9 patients survived (3 ALF and 6 ACLF) with an overall mortality rate of 55%. Low Hb, albumin and high SOFA scores were found to be poor prognostic markers.

Conclusion

Hyperammonia causing hepatic encephalopathy in liver failure carries a high mortality rate and requires prompt lowering of the ammonia level to prevent brain damage. SLED can be considered in lowering ammonia level. Large-scale studies are required to further assess efficacy of SLED in treating hyperammonia.

Keywords
Sustained low-efficiency dialysis (SLED) hyperammonia Hepatic encephalopathy liver failure.

How to Cite This Article

Sharieff S, Rafai WA, Manzoor A, Asad A, Gulraiz M, Rai HS. Role of Sustained Low-Efficiency Dialysis (SLED) in HyperammoniaPatients with Hepatic Encephalopathy. J Pak Soc Intern Med. 2025;6(1):65–70. doi:10.70302/jpsim.v6i1.2514

⭳ Download PDF

Conflict of Interest

All authors declare no competing interests.

Disclosed in accordance with ICMJE and COPE guidelines.

Funding

No specific funding was received for this research.

Funder information follows the Crossref Funder Registry standard.

References

  1. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guidelines by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatol. 2014; Doi: 10.1002/hep.27210. doi:10.1002/hep.27210
  2. Slack AJ, Auzinger G, Willars C. Ammonia clearance with hemofiltration in adults with liver disease. Liver Int. 2014;34(1):42- 48.
  3. Balata S. Induced hyperammonemia alters neuropsychology, brain MR spectroscopy and magnetization transfer in cirrhosis. Hepatol. 2003;37(4):931- 9.
  4. Kumar R, Shalimar, Sharma H, Prakash S, Panda SK, Khanal S, et al. Persistent hyperammonemia is associated with complications and poor outcomes in patients with acute liver failure. Clin Gastroenterol Hepatol. 2012;10(8):925–31.
  5. Hu C, Huang K, Zhao L, Zhang F, Wu Z, Li L. Serum ammonia is a strong prognostic factor for patients with acute-on-chronic liver failure. Sci Rep. 2020; Doi.org/10.1038/s41598-020-73603-1 doi:10.1038/s41598-020-73603-1
  6. Bernal W, Hall C, Karvellas CJ, Auzinger G, Sizer E, Wendon J. Arterial ammonia and clinical risk factors for encephalopathy and intracranial hypertension in acute liver failure. Hepatol. 2007;46(6):1844–52.
  7. Clemmesen JO, Larsen FS, Kondrup J, Hansen BA, Ott P. Cerebral herniation in patients with acute E liver failure is correlated with arterial ammonia concentration. Hepatol. 1999;29(3):648-53.
  8. Tapper EB, Jiang ZG, Patwardhan VR. Refining the ammonia hypothesis: A physiology-driven approach to the treatment of hepatic encephalopathy. Mayo Clin Proc. 2015;90: 646-58.
  9. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy—definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congress of Gastroenterology, Vienna, 1998. Hepatol. 2002; 35(4):716-21.
  10. Cordoba J. New assessment of hepatic encephalopathy. J Hepatol 2011; 54(5):1030-40.
  11. Silva F, Tavares J, Castro A, Guimas A, Freitas C, Pimentel JP, Cabrita A. Acute hyperammonemic encephalopathy – an indication for an extracorporeal depuration technique A case report and literature review. Port J Nephrol Hypert 2021; 35(1): 43-46.
  12. Scott TR, Kronsten VT, Hughes RD, Shawcross DL. Pathophysiology of cerebral oedema in acute liver failure. World J Gastroenterol. 2013;19(48):9240–55.
  13. Norenberg MD. Astroglial dysfunction in hepatic encephalopathy. Metabolic Brain Disease. 1998;13(4):319-35.
  14. Cudalbu C, Taylor-Robinson SD. Brain Edema in Chronic Hepatic Encephalopathy. J Clin Exp Hepatol. 2019; 9(3):362–82.
  15. Long MT, Coursin DB. Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022; Doi: 10.1016/j.jcrc.2022.154042 doi:10.1016/j.jcrc.2022.154042
  16. Kamboj M., Kazory A. Expanding the boundaries of combined renal replacement therapy for non-renal indications. Blood Purification. 2019;47(1-3):69-72.
  17. Sakusic A, Sabov M, McCambridge AJ, Rabinstein AA, Singh TD, Mukesh K, et al. Features of adult Hyperammonemia not due to liver failure in the ICU. Critical Care Medicine. 2018;46(9): e897-e903.
  18. Warrillow SJ, Bellomo R: Preventing cerebral oedema in acute liver failure: The case for quadruple-H therapy. Anaesth Intensive Care. 2014;42(1):78–88.
  19. Wendon J, Cordobay J, Dhawan A, Larsen FS, Manns M, Nevens F, Samuel D, Simpson KJ, Yaron I. EASL Clinical Practical Guidelines on the Management of Acute (fulminant) Liver Failure. European Association for the Study of the Liver. J Hepatol. 2017; 66 (5):1047–81.
  20. Raina R, Bedoyan JK, Lichter-Konecki U, Jouvet P, Picca S, Mew NA, et al. Consensus guidelines for management of hyperammonaemia in paediatric patients receiving continuous kidney replacement therapy. Nature Reviews. Nephrol. 2020;16(8):471-82.
  21. Bernal W, Hyyrylainen A, Gera A, Audimoolam VK, McPhail MJ, Auzinger G, et al. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients. J Hepatol. 2013; 59(1):74–80.
  22. Davenport A.: Is there a role for continuous renal replacement therapies in patients with liver and renal failure? Kidney Int Suppl 1999;72(1): S62–S66.
  23. Bernal W, Lee WM, Wendon J, Larsen FS, Williams R: Acute liver failure: A curable disease by 2024?J Hepatol 2015;62[Suppl]: S112–20.
  24. Wiegand C, Thompson T, Bock GH, Mathis RK, Kjellstrand CM, Mauer SM. The management of life-threatening hyperammonemia: A comparison of several therapeutic modalities. J Pediatr. 1980; 96(1):142-4.
  25. Goel A, Lalruatsanga D, Himanshu D, Bharti V, Sharma D. Acute Liver Failure Prognostic Criteria: It's Time to Revisit. Cureus. 2023;15(1):e33810.
  26. Wlodzimirow KA, Eslami S, Abu-Hanna A, Nieuwoudt M, Chamuleau RAFM. A systematic review on prognostic indicators of acute on chronic liver failure and their predictive value for mortality. Liver Int. 2013; 33(1): 40-52.
  27. Xiong QF, Xiong T, Huang P, Zhong YD, Wang HL, Yang YF. Early predictors of acute hepatitis B progression to liver failure. PLoS One. 2018;13(7):e0201049.
  28. Mainardi V, Rando K, Olivari D, Rey G, Castelli J, Grecco G, Leites A, Harguindeguy M, Gerona S. Mortality Analysis of Acute Liver Failure in Uruguay. Transplant Proc. 2018;50(2):465-471.
  29. Perricone G, Jalan R. Acute-on-Chronic Liver Failure: A Distinct Clinical Syndrome That Has Reclassified Cirrhosis. Clin Liver Dis (Hoboken). 2019;14(5):171-5.
  30. Machado MC, Fonseca GM, Jukemura J: Late-onset ornithine carbamoyltransferase deficiency accompanying acute pancreatitis and hyperammonemia. Case Rep Med 2013;Doi: 10.1155/2013/903546. doi:10.1155/2013/903546
  31. Warrillow S, Fisher C, Tibballs H, Bailey M, McArthur C, Lawson-Smith P, et al. Australasian Management of Acute Liver Failure Investigators (AMALFI). Continuous renal replacement therapy and its impact on hyperammonaemia in acute liver failure. Crit Care Resusc 2020;22(2):158-65.

Reference list indexed for Google Scholar and ResearchGate. DOI links resolve via doi.org.

CC BY CC BY 4.0 This article is published under the Creative Commons Attribution 4.0 International License. May be shared and adapted with attribution. © 2025 Journal of Pakistan Society of Internal Medicine.
📃 In This Issue View All
Original Article Impact of Diabetes Mellitus on Post-Operative Wound Healing in General Surgery Siddiqui FA, Noor M, Akhtar W Original Article Prevalence of Hypertension Among Urban Adults in Pakistan: A Cross-Sectional Study Khan TM, Ahmed S, Malik RA Original Article Outcomes of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Retrospective Analysis Raza SH, Butt N, Qureshi AM Original Article Cervical Cancer Screening Awareness Among Rural Women in Punjab Bibi S, Anjum R, Hassan F Original Article Neonatal Sepsis: Bacteriological Profile and Antibiogram in a Tertiary Care Hospital Iqbal M, Rashid T
👥 More by These Authors
Original Article Comparison of Ultrasound-Guided versus Landmark-Based Central Venous Catheter Insertion Zafar S, Gillani SA Review Article Thyroid Disorders in Pregnancy: Clinical Implications and Management Strategies Baig BI, Usman A Review Article Antibiotic Resistance Patterns in Community-Acquired Pneumonia: Emerging Trends Hussain I, Farooq Z Review Article Statin Therapy in Non-Alcoholic Fatty Liver Disease: A Systematic Review Nawaz F, Cheema HA, Mehmood Y
🔗 Related Articles By Keywords
Original Article Outcomes of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Retrospective Analysis Raza SH, Butt N, Qureshi AM Original Article Cervical Cancer Screening Awareness Among Rural Women in Punjab Bibi S, Anjum R, Hassan F Original Article Neonatal Sepsis: Bacteriological Profile and Antibiogram in a Tertiary Care Hospital Iqbal M, Rashid T Original Article Serum Ferritin as a Prognostic Marker in COVID-19 Severity: A Hospital-Based Study Rehman N, Sheikh I, Javed K