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To avoid the risk of cerebral herniation due to osmolarity shift during HD, osmolarity should be monitored carefully (hourly) during HD session, and dialysate formula adapted to avoid any rapid decrease in osmolarity.36 Peritoneal dialysis is of limited efficacy to remove NH 3 in children.35 Novel therapies Hypothermia to control ICP in ALF with hyperammonemia has been demonstrated to be beneficial in rats with extension of the survival time, preventing brain edema and decreasing cerebral spinal fluid ammonia