Hemodiafiltration for hepatic encephalopathy induced by Budd-Chiari syndrome in a patient with end-stage kidney disease

Abstract

A 36-year-old woman who was undergoing dialysis for end-stage kidney disease (ESKD) was admitted to our hospital with consciousness disorder. She was diagnosed with Budd-Chiari syndrome due to antiphospholipid syndrome at the age of 28 years. Her kidney function and leg edema gradually deteriorated. After initiation of hemodialysis (HD), transient loss of consciousness due to hepatic encephalopathy during HD treatment occurred frequently. Her kidney replacement therapy was changed to online hemodiafiltration (HDF), which dramatically improved her hepatic coma. Compared with HD, HDF contributed to the increase in Fischer's ratio and decrease in tryptophan level, which has a high protein-bound property. This case suggests that HDF may be beneficial for hepatic encephalopathy in ESKD patients by modulating the amino acid profile.

Keywords: Budd–Chiari syndrome; Fischer’s ratio; Hemodiafiltration; Hepatic encephalopathy; Portal-systemic shunt.

Fig. 1

Abdominal contrast-enhanced computed tomographic image obtained after percutaneous transluminal angioplasty. a, b Plain. c, d Early phase. e, f Delayed phase. The images indicate a portal-systemic shunt that connects from the inferior mesenteric vein to the left renal vein via the collateral circulation. g Construction of a vascular image to show the portal-systemic shunt

Fig. 2

Clinical course during the hospitalization. The average grade of most severe hepatic encephalopathy in a day was expressed according to the West Haven criteria. Presented are the results of the plasma amino acid analysis and the parameters associated with the blood purification at 21, 56, and 70 days after administration. Δ %CPV percent change in Δ circulating plasma volume, PRR plasma refilling rate, Kr plasma refilling coefficient, %ΔBW/h changes in body weight per hour during HD, UFR ultrafiltration rate, spKt/V single-pool Kt/V, eKt/V equilibrate Kt/V [–25]