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Abstract: SA-PO597

A Case of Hepatic Encephalopathy During Hemodialysis

Session Information

Category: Dialysis

  • 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Arman, Farid, Columbia University Irving Medical Center, New York, New York, United States
  • Mogrovejo Pintado, Pedro David, Columbia University Irving Medical Center, New York, New York, United States
  • Chang, Mariana Andrea, Columbia University Irving Medical Center, New York, New York, United States
  • Radhakrishnan, Jai, Columbia University Irving Medical Center, New York, New York, United States
  • Nestor, Jordan Gabriela, Columbia University Irving Medical Center, New York, New York, United States
Introduction

Hepatic encephalopathy (HE) is a serious neurological complication of portal hypertension (PH). A variety of dialysis-related factors can increase the risk of HE.

Case Description

A 50-year-old male with a history of nodular regenerative hyperplasia complicated by PH and recurrent ascites despite transjugular intrahepatic portosystemic shunt (TIPS) and kidney failure on hemodialysis (HD), hospitalized 2 times in 2 months for recurrent episodes of altered mental status (AMS) during HD sessions. The etiology of the AMS was suspected to be due to HE after an acute episode of confusion was witnessed during an inpatient HD treatment. Subsequent evaluation during this witnessed episode suggested worsening alkalosis during the course of his treatment (Table 1). Therefore, in subsequent HD treatments, his prescription was modified to lower blood flow rates and use of a lower bicarbonate (HCO3) bath (25 instead of 35). During the following 3 inpatient sessions, there were no more episodes of AMS. He subsequently underwent a TIPS revision which led to a complete resolution of his recurrent episodes of AMS.

Discussion

Ammonia exists in the blood as NH3 and NH4+, but only NH3 can cross the blood brain barrier (BBB). Respiratory and metabolic alkalosis favors the production of NH3, and its CSF concentration can increase 2-3 fold. As a result, we suspect that in patients with PH who have undergone TIPS, HD can augment their risk of HE. Moreover, intradialytic hypotension (IDH) can lead to increased portosystemic shunting and increased ammonia levels.
In this individual, the recurrent episodes of AMS occurring exclusively during HD sessions can plausibly be explained by a presumed increase in NH3 levels crossing the BBB and precipitating HE. The use of a lower HCO3 bath (25), and prevention of IDH, successfully temporized the patient while he awaited revision of his TIPS procedure.

 On admissionDuring AMS episodePost HD session with HCO3:25 bath
Na139141140
K4.73.24.2
Cl10297100
Carbone Dioxide172821
BUN481735
Creatinine5.983.14.91
pH7.67.65 
PCO22227