Abstract: PUB059
CRRT as Rescue Therapy for Acute Hyperammonemic Encephalopathy in Cirrhosis
Session Information
Category: Dialysis
- 801 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- D'Souza, Ashton, Rochester General Hospital, Rochester, New York, United States
- Sekar, Arjun, Rochester General Hospital, Rochester, New York, United States
Introduction
Continuous renal replacement therapy (CRRT) is indicated for all the traditional “AEIOU” indications in patients with hemodynamic instability. In addition, hyperammonemia is an emerging non-renal indication of CRRT in acute liver failure (ALF) patients. We describe a case of severe acute metabolic encephalopathy secondary to hyperammonemia treated with CRRT.
Case Description
53-year-old man with history of uncontrolled type 2 diabetes and decompensated cirrhosis complicated by esophageal varices, spontaneous bacterial peritonitis, and ascites requiring frequent paracenteses was initially admitted with upper GI bleeding associated with severe anemia (Hb 4.5 g/dL) and persistent hypotension despite massive transfusion protocol requiring vasopressors, intubation for airway protection, and EGD with banding of large esophageal varices. Labs were also notable for AKI with serum creatinine 1.57 mg/dL up from baseline 1.0 mg/dL. Due to poor urine output and rising creatinine, patient was given 1 g/kg IV albumin with stabilization of renal function. Patient remained clinically stable and was awake, alert, and able to be extubated on day 3 of hospitalization. On day 5, patient became acutely comatose with tachypnea and audible gurgling and was found to have respiratory alkalosis with pH of 7.46 on venous blood gas, and worsening hyperammonemia (325 umol/L; increased from 121 umol/L on day 2) despite being started on lactulose the previous day. Given severe metabolic encephalopathy and acute respiratory distress associated with ongoing shock, patient was urgently started on high flow CRRT without ultrafiltration, and subsequently emergently reintubated. CRRT was stopped on day 8 as hemodynamic status and alkalemia improved with normalization of serum ammonia. Mental status gradually improved and patient was extubated on day 10. Patient opted to switch to comfort-focused care the following day given overall poor prognosis and eventually was discharged to inpatient hospice where he passed away peacefully.
Discussion
CRRT has been associated with improved survival in ALF patients given sustained continuous ammonia clearance because of greater cumulative dose and lack of rebound hyperammonemia unlike intermittent HD. Early intervention is critical and aggressive reduction of serum ammonia levels with CRRT should be considered in severe hyperammonemia with rapid neurological decline.