Advances in Peritoneal Dialysis, Vol. 29, 2013 Hepatorenal Syndrome Treated for Eight Months Elliot Charen,1 Kobena Dadzie,1 Nijal Sheth,1 Hira Siktel,1 with Continuous-Flow Alan Dubrow,1 Nikolas Harbord,1 James Winchester,1 Claudio Ronco,2 Richard Amerling1 Peritoneal Dialysis The case documented here represents the longest Hypotension was managed with a combination course of continuous-flow peritoneal dialysis (PD) of blood transfusions, albumin, and vasopressors. reported in the literature. A 61-year-old man with The acute kidney injury (AKI) initially responded hepatorenal syndrome type 1 and ascites presented to resuscitative measures as listed, but then oliguria with hypotension and bright red blood per rectum and acidemia worsened, with creatinine increasing and was found to be in acute renal failure with severe to 8.65 mg/dL. The patient became more obtunded; anemia. Continuous-flow PD was initiated, and the the anasarca worsened, including reaccumulation of patient improved clinically. The patient died of a the ascites post paracentesis; and the patient became jejunal bleed 8 months later, before discharge. Acute dyspneic at rest. PD or continuous-flow PD is a viable alternative in By the 5th hospital day, palliative care was con- the setting of hemodynamic instability and ascites, sulted because of the poor prognosis of hepatorenal can be used as a chronic modality, and addresses syndrome and the patient’s ineligibility for liver trans- many of the weaknesses of continuous ambulatory plantation secondary to alcohol abuse. The renal team and automated PD. discussed the risks and possible benefits of peritoneal dialysis (PD) and continuous-flow PD (CFPD) with Key words the family, who agreed to a trial. On hospital day 12, a Continuous-flow peritoneal dialysis, acute kidney dual-lumen Ronco PD catheter (Figure 1) was placed injury, hepatorenal syndrome at bedside, and 8 L ascites was drained. The patient required intravenous albumin and Case description dopamine infusion to support his blood pressure. On A 61-year-old man with alcoholic cirrhosis, chronic hospital day 13, standard acute PD was initiated (with kidney disease (baseline creatinine 3 months before dopamine infusion) using 4 exchanges of 1.5% dex- admission: 1.5 mg/dL), and tophaceous gout presented trose solution. With a daily net negative fluid balance with hypotension and bright red blood per rectum. He of 4 – 7 L, a combination of albumin, blood transfu- denied recent use of alcohol and nonsteroidal anti- sions, saline, and dopamine were needed. On hospital inflammatory drugs. Physical exam revealed hypo- day 21, dopamine was switched to midodrine, and the tension, altered mental status, tense ascites, anasarca, patient was transferred to the general medical ward. spider angiomata of the abdomen, large tophi of both Serum albumin was consistently below 1.8 g/dL. upper extremities, muscle wasting, and cachexia. Because of persistent hypotension after 24 days Laboratory data on admission were significant of intermittent PD, CFPD was started once radio- for creatinine 5.24 mg/dL and hemoglobin 5.6 g/dL. graphic verification had been obtained that the dif- Paracentesis was negative for spontaneous bacterial fuser portion of the Ronco catheter was located in the peritonitis, and 4.6 L ascites were drained. Upper peritoneal cavity. A Fresenius 2008H hemodialysis endoscopy demonstrated no evidence of bleeding or machine with a F180NR dialyzer was used in continu- varices, only chronic gastritis. ous renal replacement therapy mode to dialyze ascites with a peritoneal fluid flow (Qp) of 300 mL/min and From: 1Division of Nephrology and Hypertension, Beth a dialysate flow of 500 mL/min. The ascitic fluid was Israel Medical Center, New York, New York, U.S.A., and dialyzed against a standard dialysate with 2.5 mEq/L 2Nephrology Division, San Bortolo Hospital, Vicenza, Italy. Ca and 4.0 mEq/L K. During each session, 2 – 4 L Charen et al. 39 FIGURE 1 Ronco 15F peritoneal dialysis catheter with diffuser. Source: C. Ronco, reproduced with permission. ascites was removed by ultrafiltration (UF). Each to enhance clearance, but because of worsening session lasted 4 – 6 hours, and 4 – 6 sessions were symptomatic hypotension, hemodialysis was stopped. delivered per week. Clearances were calculated by Eight months into the hospital admission, the the Daugirdas equation using pre- and post-treatment patient developed recurrent gastrointestinal bleeding. blood chemistries (Table I). Sigmoidoscopy was negative, and a bleeding scan re- The patient improved clinically over several vealed a jejunal bleed. The bleeding proved refractory, weeks, with clearing of anasarca (20 kg net weight and the patient died 236 days after hospitalization. reduction), control of ascites and acidosis, and with- drawal of pressors. The CFPD was continued, with a Discussion few missed treatments because of melena, worsening anemia, and punctate leaks in the external portion of Review of CFPD the catheter near the Luer connector (fixed by trim- The principle of CFPD is to maximize transperitoneal ming the tubing and inserting a new Luer connector). solute transport by maintaining a constant infusion Four months into the admission, the patient devel- of solute-free dialysate. The process requires a dual- oped an elevated white blood cell count of 15.6×109/L, lumen catheter (or 2 catheters), and either large vol- but was asymptomatic. The cell count in his peritoneal umes of fresh, sterile dialysate (single-pass, used in fluid was 3060/μL with 85% neutrophils, and a cul- pediatric AKI), or external regeneration of dialysate ture grew Streptococcus mitis and S. oralis sensitive using a hemodialysis circuit or sorbent. to ceftriaxone. The white blood cell count in ascites Continuous-flow PD was first reported by Shina- decreased promptly with antibiotics. berger et al. in 1965, with urea clearances in the range The patient’s Kt/V urea averaged 0.25 per treat- 46 – 125 mL/min (1). Those authors used 2 peritoneal ment (Table I) with a mean urea clearance (KU) of catheters with 3 L sterile dialysate refreshed by an 46 mL/min. Mean creatinine clearance (KCr) was external Kiil dialyzer and a Qp in the range 120 – 44 mL/min, mean phosphorus clearance (KPh) was 300 mL/min. During the subsequent two decades, 52 mL/min, and mean uric acid clearance (KUric) was other groups (2–5) reported urea clearances of 30 – 47 mL/min (Table II). 50 mL/min using various means of peritoneal access. The patient remained cachectic, and sessions were Since the start of the 1990s, enhanced solute clear- increased to 6 hours. The KU declined after 6 – 8 ance with CFPD has been confirmed (6–9). There have months to a mean of 24 mL/min (Table I). The KCr also been improvements in catheter design to prevent was 21 mL/min, KPh was 17 mL/min, and KUric was “streaming”—that is, channeling of dialysate causing 22 mL/min (Table II). Seven months into the hospital a maldistribution of flow (10). The newer catheters admission, an attempt was made to add hemodialysis enhance intraperitoneal (IP) dialysate mixing and 40 Hepatorenal Syndrome Treated for Eight Months with CFPD TABLE I Early and late treatment data for continuous-flow peritoneal dialysis Treatment UF Weight (kg) Volume time Qp volume BUN (mg/dL) Urea KU Date Before After (L) (min) (mL/min) (L) Before After Kt/V (mL/min) 25 Apr 81.4 77 48.8 240 300 3961 27 23 0.25 50.88 26 Apr 79.4 77.6 47.6 240 300 1800 24 21 0.21 41.69 28 Apr 78 77.3 46.8 245 300 1000 27 23 0.21 40.11 30 Apr 78.8 77.3 47.3 240 300 1500 30 24 0.32 63.04 7 May 75 71.8 45.0 260 200 3200 48 41 0.24 41.54 17 May 69.9 66.7 41.9 260 300 3065 34 29 0.25 40.33 25 May 64 62 38.4 240 300 2007 31 26 0.25 40.00 Mean (early) 75 73 45 246 286 2362 32 27 0.25 45.37 20 Aug 55.1 54.6 33.1 300 300 4200 30 26 0.26 28.65 12 Oct 55.9 52.3 33.5 360 300 3700 47 44 0.17 15.84 17 Oct 55.7 52.3 33.4 360 300 2600 51 43 0.28 25.99 Mean (late) 56 53 33 340 300 3500 43 38 0.24 23.49 Qp = peritoneal fluid flow; UF = ultrafiltration; BUN = blood urea nitrogen; KU = urea clearance. TABLE II Early and late treatment data for small solutes during continuous-flow peritoneal dialysis Creatinine (mg/dL) KCr Phosphorus (mg/dL) KPh Uric acid (mg/dL) KUric Date Before After Kt/V (mL/min) Before After Kt/V (mL/min) Before After Kt/V (mL/min) 25 Apr 3.8 3.2 0.26 52.91 4.6 3.6 0.35 71.23 26 Apr 3.4 3.0 0.18 35.73 4.0 3.5 0.22 43.67 28 Apr 3.8 3.1 0.26 49.67 4.2 3.5 0.25 47.76 30 Apr 4.1 3.3 0.32 63.04 4.5 3.5 0.35 68.95 8.2 6.6 0.28 55.16 7 May 4.2 3.7 0.21 36.35 3.3 2.9 0.21 36.35 9 7.8 0.23 39.81 17 May 5.3 4.4 0.28 45.17 6.7 5.9 0.26 41.94 25 May 3.8 3.5 0.16 25.60 4.7 Mean (early) 44.07 51.65 47.48 20 Aug 4.6 4.1 0.22 24.24 5.3 5.1 0.13 14.33 6.9 6.1 0.24 26.45 17 Oct 4.5 4.1 0.20 18.57 5.7 5.1 0.21 19.50 6.1 5.6 0.18 16.71 Mean (late) 21.41 16.91 21.58 KCr = creatinine clearance; KPh = phosphorous clearance; KUric = uric acid clearance.