Abstract: PUB487
The Utility of Renal Replacement Therapy in Hepatic Encephalopathy
Session Information
Category: Trainee Case Report
- 701 Dialysis: Hemodialysis and Frequent Dialysis
Author
- Ahuja, Ashish C., UPMC Mercy, Pittsburgh, Pennsylvania, United States
Introduction
Severe liver failure may cause the brain to swell, leading to significantly altered sensorium. In the treatment of these patients, we utilize the ability of the gastrointestinal system to clear ammonia. However, we often come across patients who do not respond to this regimen. In this case, our patient was somnolent requiring intubation and had rising ammonia levels despite lactulose and rifaximin therapy. Although he had normal kidney function, we used CRRT and noted improvement in the patient’s mental status.
Case Description
58-year-old male who has a history of cirrhosis with portal HTN who presented with shortness of breath and cough for 2 weeks. He was initially admitted for COPD exacerbation. He developed further worsening respiratory failure requiring intubation and antibiotic therapy. CT chest revealed left upper lobe pneumonia and respiratory viral panel came back positive for H1N1 so he was started on Tamiflu. His physical examination off sedation included no purposeful movements and not following commands so he continued to be intubated. Ammonia level returned at 229. He received lactulose enema, lactulose 20mg QID, and rifaximin 500mg BID through orogastric tube. Given his minimal response and rising ammonia levels, CRRT was started. The next morning, his abdomen became increasingly distended and rigid. Abdominal X-ray revealed colonic ileus. Rectal tube was placed for colonic decompression. Lactulose was switched to Miralax QID and he received another CRRT session. The following day, he had increasing output from his rectal tube. Serial abdominal X-rays revealed decreasing colonic distention. He was extubated and started to communicate, eat by mouth and eventually transferred to the floor.
Discussion
We present an interesting case of a patient who presents with acute respiratory failure secondary to H1N1 influenza along with altered mental status secondary to hepatic encephalopathy. When conservative measures fail, clinicians sometimes consider more invasive techniques for HE, such as large portosystemic shunts or liver transplantation; however, not all patients are candidates for these procedures. This case sheds light on the utility of renal replacement therapy in the management of critically ill patients, even those without pre-existing kidney dysfunction or end-organ damage. Further studies are needed to quantify the extent to which renal replacement may benefit these patients.