Cerebral Oedema and Hyperammonemia Treated Using CRRT

A 20-year-old male with no known co-morbidities came to the emergency department with a history of jaundice for five days, along with drowsiness for one day. He was admitted to Max Super Speciality Hospital, Saket, New Delhi, as a case of Acute Liver Failure (Hepatitis A virus-related) with Acute Kidney Injury (AKI), severe coagulopathy & Grade 3 Hepatic Encephalopathy secondary to Cerebral Oedema. His investigations revealed total bilirubin of 8.6 mg/dL, AST/ALT of 9403/6136 IU/L, urea of 55 mg/dL, Creatinine of 3.4 mg/dL, INR of 4.37 and serum ammonia of 947 mg/dL. In view of worsening sensorium & progressively deteriorating course, he was electively intubated and kept on ventilatory support & was treated with intravenous broad-spectrum antibiotics, anti-cerebral oedema measures, along with close hemodynamic monitoring.

The patient’s family was counselled regarding the need for emergency liver transplantation as a rescue treatment.

Given the worsening sensorium, Grade IV Hepatic Encephalopathy, AKI and marked hyperammonemia, he was started on Continuous Renal Replacement Therapy (CRRT). After about five days of critical care and liver support, the patient demonstrated dramatic enhancement in the form of improvement in sensorium & falling INR. He was extubated on Day 7 of the ICU stay and later on discharged in stable condition.

The patient is now on regular OPD follow-up, with improving liver function tests.

Despite the high mortality associated with Acute Liver Failure with Grade 4 Encephalopathy, it is possible to save selected patients through medical management alone. This case highlights the successful implementation of Continuous Renal Replacement Therapy (CRRT) in the presence of cerebral oedema, acute kidney injury and hyperammonemia as a life-saving measure in Acute Liver Failure.