Reversal of diuretic-induced hepatic encephalopathy with infusion of albumin but not colloid.
Clin Sci (Lond). 2003 Dec 16
Jalan R, Kapoor D.
In patients with cirrhosis, dehydration induced by diuretics is a common precipitant of hepatic encephalopathy (HE), which may respond to volume expansion. The mechanism of HE in this situation is not fully understood. This study evaluates the effect of plasma volume expansion on the severity of HE, plasma and urinary ammonia in patients with diuretic-induced HE. Fifteen patients with alcoholic cirrhosis and diuretic-induced HE of grade 2 or more were enrolled. In 8 patients, 4.5% Human albumin solution (HAS) was used for volume expansion and in 7 patients colloid (Gelofusine) was used. Significant improvement of HE grade was observed at 24 hrs and was sustained at 72 hrs (p<0.05) only in the group treated with HAS. There were similar and statistically significant reduction in plasma ammonia concentration, plasma renin activity and angiotensin II and, an increase in mean arterial pressure, renal plasma flow and urinary ammonia excretion, in both groups. Plasma malondialdehyde was elevated in both groups but was significantly reduced only in the group treated with HAS. The results of this study show that plasma volume expansion results in significant reduction in plasma ammonia concentration possibly through an increase in urinary ammonia excretion. This reduction in ammonia concentration translates into an improvement in mental state only in those patients treated with HAS in whom concomitant reduction in oxidative stress was observed. These data support the notion that other factors such as oxidative stress act as adjuncts to ammonia in the pathogenesis of diuretic-induced HE and suggest a possible role for albumin infusion in its treatment.