Continuous kidney replacement therapy for management of hyperammonemia and hepatic encephalopathy in pediatric acute liver failure

Abstract Objectives This study aimed to evaluate the impact of continuous kidney replacement therapy (CKRT) on the outcomes of pediatric acute liver failure (PALF). Methods This was a retrospective analysis of PALF presenting to a tertiary care pediatric hepatology center between January 2012 and August 2024. Cases of PALF where CKRT was initiated within 24 h of admission for nonrenal indications (hyperammonemia, hepatic encephalopathy [HE]) were identified and outcomes compared to a propensity‐matched cohort of controls not receiving CKRT. The primary outcome measures were native liver survival (NLS) and overall survival (OS) at Day 28. Results A total of 448 patients with PALF were admitted during the study period, of which 94 had received CKRT. Thirty‐eight (40.4%) of them who received CKRT for renal indications were excluded. The remaining 56 (59.6%) received CKRT for hyperammonemia and HE. The NLS in the CKRT and no CKRT groups were 46.4%, and 52.1%, respectively, while the OS in the two groups was 53.6%, and 61.3%, respectively. In the propensity‐matched cohort (52 in each arm), there was a statistically insignificant trend toward higher NLS (46.2% vs. 36.5%, p = 0.304) and OS (53.8% vs. 44.2%, p = 0.291) in CKRT group compared to controls. Patients receiving CKRT had lower ammonia ( p = 0.016) and bilirubin ( p = 0.008) levels on Day 4, while international normalized ratio and lactate levels remained comparable. Conclusion CKRT led to significant reduction in ammonia on Day 4 in PALF; however, this did not translate into improved NLS and OS.