Cirrhosis/Hepatic Encephalopathy

My mother is on hemodialysis and is also having to deal with portal hypertension/cirrhosis/hepatic encephalopathy. These conditions are still on the mild-moderate level. Do you have dialysis patients in the same situation and if so, do you have any special treatment plans for them(e.g.-intravenous branched chain amino acid) . I realize these conditions are more in the area of gastroenterology but I was wondering if there are any special considerations for dialysis patients.

Re: Albumin Dialysis for Hepatic Encephalopathy

Unfortunately and as a prelude to my answer, despite a 38 year-long career in dialysis (which is still going, though some might say it’s gone too long), chronic maintenance dialysis complicated by hepatic encephalopathy is a problem I have only ever dealt with once or twice and even that brief exposure was some time ago. Hepatic encephalopathy +/- CKD is likely seen more often in a maintenance dialysis service co-located with a liver transplant service – and in our state of Victoria, there is only one such unit and it resides at another institution.

As a result, I can only fairly quote from the literature experience of others. Although there are a number of papers on this subject in the literature, there is a recent and good paper on the outcome of albumin dialysis or, as it is properly called, MARS (Molecular Adsorbent Re-circulating System) and the ability of this variant of dialysis to reduce the levels of circulating free phenolic aromatic amino acids and improve outcomes for patients with hepatic encephalopathy. This paper comes from a group in Barcelona, Spain, and was reported in Critical Care in 2009. It can be found at:

Even this reported experience, as I understand it, was in an acute rather than a chronic treatment setting. As you will likely know, encephalopathic episodes in hepatic cirrhosis tend to be intermittent. As such, these episodes will most commonly need intermittent acute intervention applied over and above any chronic background dialytic treatment that is being given for CKD. Though regrettably my experience in this area is minimal, I surmise that your mother’s chronic maintenance dialysis may similarly need acute intervention with something like MARS interposed on top of her chronic dialysis in order to control intermittent episodes of encephalopathy.

The key messages from this Spanish paper (and there are many others in the literature I have not referenced) are copied below. I have taken the liberty to slightly modify their key points for the purposes of lay-clarity for you – though I have not altered their meaning or their intent …

  • Albumin dialysis appears to result in favourable effects in patients with severe alcoholic hepatitis. Hepatic encephalopathy improved in all the cases cited by the Barcelona group.

*The total amino acid and phenolic aromatic amino acid burden were both reduced (= a good result) and the Fischer ratio (a scoring system for the ratio of branched amino acids) was increased (= a good result) in the patients with alcoholic hepatitis that they treated with ‘albumin dialysis’ (ie: MARS).

  • Changes in amino acid levels and the Fischer ratio were more prominent in patients with hepatic encephalopathy and a low albumin concentration and who had a greater bilirubin extraction with MARS treatment.

  • Although the mechanisms by which albumin dialysis decreases the levels of phenolic aromatic amino acids in patients with severe alcoholic hepatitis remain unknown, it could be speculated that MARS may be able to dialyse and/or adsorb the free circulating levels of these amino acids in patients where the blood albumin concentration is already low and the albumin is already completely saturated and is thus unable to bind or transport more substances.

I am sorry I cannot help much more with this. It may be useful, if you need further information, to seek out if and where liver transplants are done nearby where your mother is being dialysed. You could then contact the chronic maintenance dialysis service attached to that institution. Such a service is more likely to be able to offer you direct and detailed specific information than I can about the combination of CKD and maintenance dialysis on the one hand coupled, on the other, with the control of acute hepatic encephalopathy.

John Agar