Abstract: PUB021
Improved Dialysis Tolerance and Reduced Vasopressor Requirements After Droxydopa Initiation in Refractory Shock in a Patient with Decompensated Liver Disease
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Heintze, David, Medical University of South Carolina, Charleston, South Carolina, United States
- Antley, Mckinley H., Medical University of South Carolina, Charleston, South Carolina, United States
- Mazoury, Shaghayegh, Medical University of South Carolina, Charleston, South Carolina, United States
- McMahon, Blaithin A., Medical University of South Carolina, Charleston, South Carolina, United States
Introduction
Droxydopa is an oral norepinephrine precursor approved for neurogenic orthostatic hypotension and has emerging off-label use as an adjunct in refractory vasoplegic shock. Its role in patients with advanced liver disease and concurrent acute kidney injury (AKI) remains poorly described.
Case Description
We present a 31-year-old woman with autoimmune hepatitis status post liver transplant (complicated by rejection requiring repeat transplant) who presented with encephalopathy, jaundice, and poor oral intake concerning for subacute liver failure. Her course was complicated by distributive shock requiring ICU admission and norepinephrine plus vasopressin following biliary and infectious complications, including candidemia and Enterococcus bacteremia. ERCP demonstrated migration of a prior biliary stent, which was replaced.
She developed worsening encephalopathy and multifactorial acute kidney injury felt most consistent with acute critical illness causing tubular necrosis with a component of bile cast nephropathy. She required a short course of CRRT for uremia and concern for cefepime-associated neurotoxicity. Given persistent vasoplegia and fluctuating vasopressor requirements, droxidopa 100 mg TID was started with concurrent midodrine. Within 24 hours, norepinephrine requirements decreased from 8–10 mcg/min to 0–2 mcg/min, with intermittent ability to discontinue IV vasopressors entirely. Mean arterial pressure improved and became less labile. Vasopressin had been discontinued shortly before droxidopa initiation and just after starting midodrine. No adverse effects were observed in relation to droxidopa.
Discussion
Patients with advanced liver disease and critical illness frequently develop profound vasodilatory shock that may be refractory to standard IV vasopressors. These patients in particular have a susceptibility to intradialytic hypotension. Droxydopa, in combination with midodrine, may serve as a novel enteral adjunct to reduce catecholamine requirements and improve hemodynamic stability in selected patients with dialysis ependence, vasoplegic physiology and concurrent AKI. This case highlights a potential role for oral sympathomimetic therapy in facilitating IV vasopressor weaning in complex shock in liver disease patients, though causality cannot be established in a single case.