Clinical Science (2004) 106, 467–474 (Printed in Great Britain)
Reversal of diuretic-induced hepatic
encephalopathy with infusion of albumin
but not colloid
Rajiv JALAN and Dharmesh KAPOOR
Liver Failure Group, Institute of Hepatology, University College London Medical School, London WC1E 6HX, U.K.
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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. The present 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 eight patients, 4.5 % human albumin solution (HAS) was used for volume expansion and in seven
patients colloid (Gelofusine® ) was used. Significant improvement of HE Grade was observed at
24 h and was sustained at 72 h (P < 0.05) only in the group treated with HAS. There were similar
and statistically significant reductions 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 reduced
significantly only in the group treated with HAS. The findings of the present 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.
INTRODUCTION
In patients with cirrhosis, ammonia [throughout the
text, ammonia is used to denote ammonia (NH3 ) and
ammonium (NH4 + ) unless the two entities are specified
separately] is thought to be central in the pathogenesis of
hepatic encephalopathy (HE) [1,2]. The organs that are
thought to be primarily responsible for the homoeostasis
of ammonia are the gut and liver [3]. Recent studies in
patients with cirrhosis have indicated an important role
for the muscle and kidneys in maintaining ammonia levels
[4,5]. The kidneys dispose of ammonia following its
production from glutamine through secretion (proximal
convoluted tubule), reabsorption and concentration
through counter-current multiplication (ascending limb
of the loop of Henle and medullary interstitium) and,
finally, secretion into the collecting ducts [6]. In the
physiological state, most of the ammonia generated by
the kidney is returned to the systemic circulation and
a smaller proportion is excreted in the urine [7,8]. This
ratio is reversed in patients with cirrhosis, as the kidney
becomes net ammonia ‘disposer’ [7,8]. Acidosis promotes
renal ammonia production and transport [9]. Chronic
hyperkalaemia decreases ammonium production in the
Key words: albumin, dehydration, hepatic encephalopathy, plasma ammonia, urinary ammonia excretion.
Abbreviations: ANG, angiotensin; Dsst, digital symbol substitution test; GFR, glomerular filtration rate; HAS, human albumin
solution; HE, hepatic encephalopathy; MDA, malondialdehyde; PRA, plasma renin activity; RPF, renal plasma flow.
Correspondence: Dr Rajiv Jalan (e-mail [email protected]).
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proximal tubule and whole kidney, inhibits absorption of
NH4 + , reduces medullary interstitial concentrations
of NH4 + and NH3 , and decreases entry of NH4 + and
NH3 into the medullary collecting duct [10,11]. Other
potent stimuli modulating ammonia synthesis, transport
and excretion by the kidneys include renal blood flow,
tubular cell pH and renal tubular lumen pH, luminal flow
rate and angiotensin (ANG) II levels [12,13].
One of the common precipitating factors for the development of HE in patients with cirrhosis is diureticinduced dehydration. The mechanisms by which dehydration induces HE is unclear, but a contraction of
the intravascular volume and its redistribution may reduce renal blood flow and, therefore, renal ammonia
excretion. Renal ammonia excretion may be compromised further by activation of the renin–aldosterone–
angiotensin axis, impacting upon renal ammonia excretion [12,13]. Furthermore, dehydration induces oxidative
stress, which may exacerbate the neuropsychological
effects of hyperammonaemia [14–16].
We have shown recently [17] that volume expansion
in cirrhotic patients results in a reduction in plasma ammonia concentrations and an increase in urinary ammonia
excretion. The aims of the present study were to
determine the effect of volume expansion on the mental
state, plasma ammonia and urinary ammonia excretion
and a marker of oxidative stress in cirrhotic patients with
diuretic-induced HE. We studied two groups of patients
consecutively. The first group received volume expansion
with 4.5 % human albumin solution (HAS; Baxter
Bioscience, Newbury, Berks., U.K.) and the second
group received colloid (Gelofusine® ; Braun Medical Ltd,
Aylesbury, Bucks., UK).
Table 1 Patient characteristics
Values are means +
− S.E.M., or means (range). HCV, hepatitis C virus.
Age (years)
Sex (male/female)
Aetiology of cirrhosis
Alcohol
Alcohol + HCV
Severity of liver disease
Child Class B
Child Class C
Bilirubin (umol/l)
Prothrombin time (s)
Albumin (g/l)
Severity of ascites
Moderate
Severe
Diuretics on admission
Spironolactone (mg)
Frusemide (mg)
Severity of HE on admission
Grade 3
Grade 2
HAS group (n = 8)
Colloid group (n = 7)
47.3 +
− 4.4
6/2
50.1 +
− 6.1
4/3
7
1
5
2
1
7
56.3 +
− 5.2
16.7 +
− 2.4
27.1 +
− 3.2
1
6
61.9 +
− 6.8
15.9 +
− 4.6
29.1 +
− 3.3
4
4
5
2
250 (150–400)
40 (20–80)
200 (100–400)
60 (20–120)
3
5
2
5
End point for volume expansion
The amount of fluid (HAS or Gelofusine® ) administered
was guided by the central venous pressure and urine
output. The aim was to administer fluids intravenously
until the central venous pressure was sustained at between
7–10 mmHg.
Inclusion criteria
METHODS
Ethical approval
This prospective controlled study was conducted with
informed and written assent from next-of-kin, with the
approval of the Local Research Ethics Committee, and
in accordance with the Declaration of Helsinki (1989) of
the World Medical Association.
Patients
Fifteen patients with alcoholic liver disease (ten male
and five female) and diuretic-induced HE of Grade 2
or more were enrolled. The patients had stable cirrhosis
at their last outpatient follow-up and had been receiving
standard diuretic therapy, which included spironolactone
and frusemide. The first eight patients were treated with
4.5 % HAS (HAS group) for volume expansion and the
subsequent seven patients received colloid (Gelofusine® ;
Colloid group). There were no significant differences in
the patient characteristics between the HAS and Colloid
groups (Table 1).
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2004 The Biochemical Society
Patients were included into this study if they had (i) HE of
Grade 2 or higher (West Haven criteria) [18], and (ii) HE
was precipitated by dehydration (diuretic usage, oliguria,
clinical evidence of dehydration and low central venous
pressure).
Exclusion criteria
The patients were excluded if they had evidence of preadmission renal dysfunction (haematuria/proteinuria),
cardiac impairment or focal neurological abnormalities,
any symptoms or signs of alcohol withdrawal, hepatic
or extrahepatic malignancy, presence of other known
precipitants of HE, such as sepsis and gastrointestinal
bleeding, use of sedative narcotics and constipation, and
administration of any specific therapy for HE, such as
lactulose or bowel enemas, prior to enrolment.
Study design and management
If the patients fulfilled the inclusion criteria, they
were recruited into the study within 6 h of admission
[median, 6 (range, 4.5–8) h] and managed according
to a standardized protocol. Prior to inclusion into the
Reversal of diuretic-induced encephalopathy by albumin infusion
study, both groups of patients had already started to
receive intravenous fluids [HAS group, 330 (range, 220–
500) ml of Gelofusine® ; Colloid group, 410 (range, 180–
580) ml of Gelofusine® ]. The patients were managed
in a high-dependency environment. All the diuretics
were discontinued; a nasogastric tube was passed into
the stomach for providing a pre-fixed volume of water
during the experiment and kept in place for subsequent
enteral nutrition. Peripheral venous cannula and a central
venous catheter (Arrow International Inc., Reading, PA,
U.S.A.) were inserted. An arterial blood gas sample
was obtained prior to randomization (CO-Oximeter
482; Instrumentation Laboratory, Warrington, Cheshire,
U.K.). Cardiovascular monitoring included the hourly
measurement of blood pressure (Dynamap; Critikon,
North Ryde, Australia) and heart rate. Blood urea nitrogen, serum creatinine and plasma sodium and potassium
were measured using an auto-analyser (Olympus Reply
Autoanalyser; Olympus Optical Ltd, Tokyo, Japan).
Requisite cultures (blood, urine and ascites) were taken
at the bedside to establish the contribution of a possible
‘occult’ infection to the HE. All patients were fed through
the nasogastric tube with an enteral meal providing
146 kJ/kg, 1 g/kg of protein, 100 mmol sodium, 40 mmol
potassium and 60 ml/h of fluid. This meal was given over
a period of 20 h and stopped 1 h prior to the study on
day 1 (24 h) and day 3 (72 h). Each study period was of
3-h duration and all clinical, biochemical, neuropsychiatric and haemodynamic tests were repeated after 24 and
72 h of admission.
Neurological assessment
Neurological assessment was performed at the time of
inclusion into the study and then at 24 and 72 h. Severity
of HE was assessed using the West Haven criteria [18].
Tests of neuropsychiatric function (Trails B test; the test
had to be completed within 420 s) and digital symbol
substitution test (Dsst; the test score was the number of
symbols correctly substituted in 90 s) were administered
by a single investigator and scored as described previously
[19,20].
Glomerular filtration rate (GFR) and
renal plasma flow (RPF)
Primed continuous infusion of inulin (Inutest, 25 %;
Laevosan-Gesellschaft, Linz, Austria) and para-amino
hippuric acid (Merck Sharpe and Dohme, Sydney,
Australia) were used as markers of GFR and RPF
respectively [17,21].
Sampling and measurements
Plasma samples for circulating neurohormones [ANG II
and plasma renin activity (PRA)] and plasma ammonia
were taken. Blood was collected from a peripheral vein
into pre-cooled tubes. Plasma was separated and the
samples stored at − 70 ◦ C for analysis at a later date. Urine
was collected in a pre-cooled bottle which was maintained
acidified with 2 ml of 6.0 M HCl in the urine collector,
as described previously for measurement of ammonia,
inulin and para-amino hippuric acid [17,21,22]. Inulin
concentration was measured using spectrophotometry,
and PAH was measured using HPLC [21,22].
PRA
The RIA for measurement of PRA was based on the
principle that ANG I is generated by the action of renin
on its substrate angiotensinogen. An in-house antibody
for ANG I was used. The coefficient of variation for
the assay was 5.2 %. The reference range for PRA was
−1
−1
1.6 +
− 1.5 ng · h · ml [17,21].
ANG II
Samples of blood were obtained in ANG II inhibitor.
ANG II values were measured by RIA with an in-house
rabbit antibody R6B4. The coefficient of variation for
the assay was 3.2 %. The reference range for ANG II was
3.2 +
− 1 pg/ml [17,21].
Plasma and urinary ammonia
Samples for ammonia estimation were kept on ice during
processing. Ammonia was measured using standard
enzymic method, as described previously [22]. The coefficient of variation for all determinations was < 4 %.
Malondialdehyde (MDA)
MDA was determined using a modified TBARS (thiobarbituric acid reactive substances) assay as described
previously [23]. Control values for our laboratory were
0.9 +
− 0.2 µmol/l.
Calculations
Urinary sodium, urinary ammonia and urinary volume
values were used to derive the following parameters as
follows:
Urinary ammonia excretion (mmol/h)
= urinary ammonia × urinary volume
Fractional excretion of ammonia (%)
= (urinary ammonia excretion/filtered sodium load)
× 100
Ammonia clearance (ml/min)
= urinary ammonia excretion/plasma ammonia
Statistical analysis
All the data are expressed as means +
− S.E.M. The
significance of changes within the study group was tested
using one-way ANOVA during each of the three periods
of observation (T = 0, T = 24 h and T = 72 h). A post-hoc
analysis was done assuming unequal variance, using the
Dunnett’s C test. Difference between groups was tested
using two-way ANOVA. Relationship between variables
was tested using linear regression. A P value < 0.05 was
taken to be statistically significant.
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Table 2 Changes in biochemistry, renal haemodynamics, plasma ammonia and urinary ammonia excretion after volume
repletion
All values are means +
− S.E.M. Blood gases measurements were available in all patients at baseline (0 h), but in only four patients in each group at 72 h. UNH3 V,
urinary ammonia excretion; UNaV, urinary sodium excretion; FENH3 , fractional excretion of ammonia; NH3 Cl, ammonia clearance; ∗ P < 0.05, ∗∗ P < 0.01 and
∗∗∗
P < 0.001 (by one-way ANOVA) compared with baseline (0 h).
HAS group (n = 8)
0h
Heart rate (beats/min)
Mean arterial pressure (mmHg)
Central venous pressure (mmHg)
Serum sodium (mmol/l)
Serum potassium (mmol/l)
Albumin (g/l)
Blood gases
pH
HCO3 (mmol/l)
Urea (mmol/l)
Creatinine (µmol/l)
RPF (ml/min)
GFR (ml/min)
UNaV (mmol/h)
Plasma ammonia (µmol/l)
Urinary volume (ml/h)
UNH3 V (mmol/h)
FENH3 (%)
NH3 Cl (ml/min)
ANG II (pg/ml)
PRA (ng · h−1 · ml−1 )
Colloid group (n = 7)
24 h
72 h
0h
96 +
−3
70 +
−2
1.1 +
− 0.5
125 +
− 1.8
3.2 +
− 0.1
27.1 +
− 3.2
∗
83 +
−4
+
81 − 2∗
∗∗
9.3 +
− 1.2
+
130 − 3.1
∗
3.6 +
− 0.1
+
30.1 − 2.6∗
∗
77 +
−2
+
81 − 2∗∗
∗∗
9.9 +
− 1.3
+
130 − 1.2∗
∗∗
3.9 +
− 0.1
+
28.8 − 2.5∗
101 +
− 3.7
73 +
− 3.4
−1+
− 4.1
128 +
− 3.4
3.5 +
− 0.3
29.1 +
− 3.3
7.36 +
− 0.1
20.3 +
− 0.7
20.3 +
− 2.3
197.5 +
− 24.5
221.4 +
− 21.3
15.7 +
− 2.5
14.4 +
− 1.9
98.0 +
− 7.3
10.1 +
−1
0.4 +
− 0.04
385.3 +
− 32.3
63.7 +
− 8.1
325.2 +
− 20.5
30 +
−3
–
–
∗
13.2 +
− 1.1
134.3 +
− 14.3
∗∗
362.8 +
− 29.2
∗∗
37.4 +
− 3.7
∗
33.3 +
− 8.3
∗∗
64.6 +
− 4.2
∗∗
48.6 +
−6
∗∗
1.2 +
− 0.3
∗
895.1 +
− 49.6
∗∗∗
312.9 +
− 38.7
∗∗
167.5 +
− 19.1
∗∗
17 +
−3
7.43 +
− 0.1
∗
23.1 +
− 0.4
∗
11.2 +
− 1.9
∗
99 +
− 9.7
∗∗
325.1 +
− 40
∗∗
39.6 +
− 2.3
∗∗
49 +
− 10.1
∗∗
52.7 +
− 4.9
∗∗∗
55.7 +
− 13
∗∗∗
1.2 +
− 0.1
∗∗
1050.8 +
− 187.9
∗∗
403.1 +
− 61.5
∗∗∗
143.7 +
− 19.0
∗∗
10 +
−1
7.38 +
− 0.1
18.4 +
− 0.4
18.4 +
− 2.4
183.3 +
− 18
197 +
− 14.7
13.7 +
− 1.1
19.2 +
− 4.1
89.1 +
− 6.1
13.1 +
− 2.0
0.3 +
− 0.10
345.5 +
− 70.7
46.8 +
− 9.3
229.3 +
− 42.1
26.1 +
− 5.9
RESULTS
24
∗
79 +
− 3.2
+
84 − 2.9∗
∗∗
7.8 +
− 1.2
+
131 − 2.9∗
∗
4.1 +
− 0.2
+
27.2 − 4.3
–
–
∗
9.5 +
− 3.1
∗
121 +
− 11.3
∗
357.0 +
− 35.5
∗∗
38.3 +
− 4.4
∗
39.1 +
− 5.9
∗∗
70.9 +
− 2.0
∗∗
55.1 +
− 4.2
∗∗
1.1 +
− 0.1
∗∗
735.8 +
− 109.8
∗∗
264.6 +
− 26.8
∗
185.6 +
− 18.2
∗
11.2 +
− 2.8
72 h
∗
81 +
− 2.9
+
85 − 3.9∗
∗∗
9.3 +
− 2.1
+
132 − 2.2∗
∗
3.9 +
− 0.3
+
27.4 − 4.5
7.43 +
− 0.4
∗
22.1 +
− 0.3
∗
7.6 +
− 3.3
∗
104 +
− 13.5
∗∗
380.4 +
− 23.8
∗∗
45.4 +
− 2.5
∗
41.1 +
− 9.1
∗∗
51.7 +
− 3.4
∗∗
63.0 +
− 2.0
∗∗
1.3 +
− 0.1
∗∗
931.7 +
− 113.0
∗∗
424.4 +
− 59
∗∗
93.1 +
− 24.2
∗∗
8.2 +
− 2.9
group. There was an insignificant reduction in serum
albumin in the Colloid group (Table 2).
Systemic haemodynamics and electrolytes
Both groups of patients showed evidence of severe
dehydration indicated by tachycardia, hypotension, low
central venous pressure and poor urine output. They
had elevated urea and creatinine, reduced serum sodium
and potassium and showed evidence of mild metabolic
acidosis. Volume resuscitation resulted in a significant and
sustained increase in the central venous pressure in both
groups. In the first 24 h, the target central venous pressure
(7–10 mmHg) was attained and sustained with 2.5 +
−
0.8 litre of HAS in the HAS group and 2.9 +
− 1.2 litres
of Gelofusine® in the Colloid group (P = 0.19 between
groups). In the following 48 h, a further 0.9 +
− 0.2 litres
of HAS was administered to the HAS group and 1.4 +
−
0.6 litres of Gelofusine® to the Colloid group to sustain
the increase in central venous pressure. Volume resuscitation was associated with a significant and sustained
increase in mean arterial pressure, serum sodium and
potassium, a decrease in the heart rate and correction
of the metabolic acidosis. Serum albumin increased significantly from 27.1 +
− 3.2 g/litre at baseline to 30.1 +
− 2.6 g/
litre at 24 h to 28.8 +
− 2.5 (P < 0.05) at 72 h in the HAS
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2004 The Biochemical Society
Severity of HE
HE Grade
Both groups of patients had similar severity of HE at
baseline. There was a significant improvement in the HE
Grade in the patients in the HAS group at both 24 and
72 h (P < 0.01), which was not observed in the patients
in the Colloid group (P = 0.21). In the HAS group, three
patients had Grade 3 HE, which improved to Grade 2
in two patients and Grade 1 in one patient at 24 h, and
further to Grade 1 in one patient at 72 h. One patient remained with Grade 2 HE at 72 h. Of the five patients
with Grade 2 HE, improvement to Grade 1 occurred in
four patients at 24 h and at 72 h in one patient (Figure 1A). In the Colloid group, of the two patients with
Grade 3 HE, improvement to Grade 2 HE occurred in
one patient at 72 h. The other patient remained in Grade 3
HE. Of the five patients with Grade 2 HE, improvement
to Grade 1 occurred in one patient at 24 h and at 72 h
in one patient. The other three patients remained at
Grade 2 HE (Figure 1B).
Reversal of diuretic-induced encephalopathy by albumin infusion
Figure 1 Change in the clinical Grade of HE following volume repletion in patients receiving HAS (A) and Colloid (B)
Time 0 refers to the time the patients were entered into the study.
Figure 2 Changes in neuropsychological tests [Trails B test
(A) and Dsst (B)] following volume repletion in the patients
receiving HAS or Colloid
Data are expressed as means +
− S.E.M. Time 0 refers to the time the patients
were entered into the study. Normal values from an age- and sex-matched group:
Dsst, 44 (range, 36–52); Trails B test: median, 84 (range, 61–92).
Neuropsychological tests
At baseline, it was not possible to perform the
neuropsychological tests in three patients in the HAS
group and in two patients in the Colloid group, because
of the severity of HE. In the remaining patients, the
performance of the patients for Trails B test and Dsst was
similar. There was a significantly greater improvement in
the Trails B test and also in the Dsst in the HAS group
compared with the Colloid group (P < 0.01 using twoway ANOVA; Figure 2).
Change in renal function tests, renal
haemodynamics and circulating
neurohormones
Volume resuscitation resulted in similar and significant
increases in urine output at 24 and 72 h in both groups.
The increase in urine output was possibly due to increased
RPF and GFR, both of which increased similarly and
significantly in both groups. This resulted in a significant
and sustained reduction in serum urea and creatinine
in both groups, which was not significantly different.
PRA and ANG II decreased significantly following
volume repletion in both groups at 24 and 72 h. The
reduction was similar in the two groups. The increase
in the RPF correlated with the decrease in ANG II
(r = 0.61, P = 0.01), but not with that of PRA (r = 0.44,
P = 0.07). Similarly, the increase in GFR correlated with
the decrease in ANG II (r = 0.75, P = 0.002) and PRA
(r = 0.89, P < 0.001).
Plasma and urinary ammonia
At baseline, plasma ammonia concentration was high in
both groups of patients and not significantly different
from each other. With volume repletion, plasma ammonia
was reduced significantly in both groups. This reduction
in plasma ammonia was observed at 24 h, but sustained
at 72 h, and was similar in both groups, which was
associated with significant increases in urinary ammonia
excretion and ammonia (Table 2). The decrease in plasma
ammonia levels correlated with the increase in urinary ammonia excretion (r = 0.97, P = 0.001). The change
in plasma ammonia levels also correlated with the decrease in the levels of ANG II (r = 0.75, P = 0.002) and
PRA (r = 0.79, P = 0.001). The change in urinary ammonia excretion correlated with the decrease in the levels
of ANG II (r = 0.79, P = 0.001) and PRA (r = 0.82, P =
0.001).
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Figure 3 Plasma concentration of MDA in the patients
receiving HAS or Colloid at the time of entry into the study
(0 h) and then 24 and 72 h afterwards
Values are means +
− S.E.M.
Plasma MDA
Plasma MDA levels were similar and elevated in both
groups of patients. Following volume repletion, a
significant reduction was noted only in the patients in
the HAS group. This reduction was evident at 24 h and
sustained at 72 h. No significant change was seen in the
Colloid group (Figure 3).
DISCUSSION
The present study is the first to explore the pathophysiological basis and the role of volume expansion
in the treatment of patients with diuretic-induced HE.
The result of this study highlights two important
observations. Volume expansion resulted in significant
and sustained reduction in plasma ammonia, which was
associated with a significant increase in urinary ammonia
excretion. Of significant interest was the observation
that, although the improvement in systemic and renal
haemodynamics and reduction in plasma ammonia were
similar in the patients treated with HAS and Gelofusine® ,
the improvement in HE was significantly more marked
in the patients treated with HAS. The significantly greater
reduction in MDA levels in patients treated with HAS
points to the role of oxidative stress as an important
adjunct to ammonia in the pathogenesis of diureticinduced HE.
Diuretic-induced dehydration is a common precipitating factor for HE [24,25]. The present study was
conceived following our initial observation [17] that
volume expansion with saline in patients with wellcompensated cirrhosis resulted in a decrease in plasma
ammonia and an increase in urinary excretion of ammonia. In keeping with our previous observation [17],
volume repletion resulted in an increase in urinary
ammonia excretion with consequent decrease in plasma
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2004 The Biochemical Society
ammonia levels. It is likely that the change in ammonia
homoeostasis following volume expansion is probably
due to an increase in luminal flow rate mediated by
improved renal perfusion [26], the cessation of diuretic
therapy [6], which is known to inhibit the transporters
involved in the excretion of ammonia, and/or a reduction
in renal ammoniagenesis mediated by a decrease in
ANG II, which is an important modulator of the ammonia that is synthesized by the proximal tubule [11,27–31].
In the present study, the significant correlation between
a decrease in ANG II and plasma ammonia level on one
hand and an increase in urinary ammonia excretion on
the other supports this hypothesis, but does not prove
unequivocally a cause–effect relationship.
The most important result of the present study was the
observation that there was a significantly greater improvement in HE in patients treated with HAS compared
with those treated with Gelofusine® , despite a similar
reduction in the plasma ammonia concentrations. This
implies that the mechanism by which albumin infusion
resulted in an improvement in HE is likely to be more
than that produced by volume expansion alone. Human
albumin is a 66 kDa molecule, constituting 50 % of the
plasma proteins in healthy individuals. It has been used
essentially as a plasma volume expander in the treatment
of liver disease [32–34]. Although albumin infusion was
associated with significant increases in the concentration
of albumin, the increment was modest. This may reflect
the fact that albumin is distributed very widely in the
body and the relatively large volume of distribution
in cirrhotic patients due to the concomitant ascites.
Albumin has the ability to bind to a range of different
molecules and act as a scavenger. It has a strong negative
charge and binds reversibly to both cations and anions.
These include a large number of metabolites, including
fatty acids, bilirubin, bile salts, amino acids and nitric
oxide. It is also the major extracellular source of reduced sulphydryl groups. These scavenge reactive oxygen
and nitrogen species, especially superoxide, hydroxyl and
peroxynitrite radicals. Albumin can also limit the production of these reactive species by binding free Cu2+ ,
which is known to be important in accelerating the
production of free radicals [32–34]. Interestingly, albumin
administration in sepsis patients led to significantly
increased levels of both plasma albumin and total plasma
thiols [35]. Albumin may thus influence the redox balance
and reduce oxidative stress [33,34]. In keeping with this
hypothesis, we were able to show a significant reduction
in MDA levels, which is a well-recognized marker of
oxidative stress. This reduction in MDA was not observed
in the patients in the Colloid group. It is interesting to
note that both groups of patients had markedly increased
MDA levels at baseline, which may either reflect the
effect of dehydration and/or severe cirrhosis, as increased
oxidative stress is well-described in both situations. The
results of our present study point to an important role
Reversal of diuretic-induced encephalopathy by albumin infusion
of factors that act in concert with ammonia in the
pathogenesis of diuretic-induced HE [14–16]. Clearly,
these factors are likely to have an important albuminbinding component and, as we have shown in the present
study, one such factor may be reactive oxygen species.
There is emerging evidence suggesting that oxidative
stress plays an important role in the development of
HE [36–39], possibly by causing mitochondrial damage,
including oxidation of membrane phospholipids and
various enzymes involved in energy metabolism [39–
42]. Alternatively, the effects of albumin infusion may be
through its effects on cerebral blood flow. Several studies
have suggested that, in patients with cirrhosis, there is
a redistribution of cerebral blood flow, particularly in
the frontal cortex [43,44]. Ginsberg and co-workers [45]
have shown that albumin infusion can increase cerebral
blood flow. Another possible explanation, which is more
difficult to substantiate, is that gelatin infusion may, in
some ill-defined manner, have interfered with recovery
from HE. In future studies, control arms should include
other fluids such as saline.
Our data question the role of conventional ammonialowering strategies, such as lactulose, non-absorbable
antibiotics and bowel enemas, in the treatment of
diuretic-induced HE. Simple intervention with fluid
therapy results in a significant and substantial reduction in
plasma ammonia concentration without any conventional
ammonia-lowering strategy by simply targeting the
kidneys, supporting our recent studies suggesting that
the kidneys are important in ammonia homoeostasis
[4,15,17].
The use of albumin infusion in critically ill patients
is a subject of considerable debate following a recently
published meta-analysis [46], suggesting poor outcome
of critically-ill patients that were treated with albumin
compared with other colloids. This meta-analysis has
been criticized and the issue of the use of albumin
as a volume expander in critically ill patients is being
explored in controlled clinical trials [47–49]. In patients
with liver disease, the use of albumin infusion as a volume
expander has been studied in considerable detail. Studies
[50,51] have shown that albumin infusion following
paracentesis is associated with a lower incidence of
renal dysfunction compared with other colloids [32].
In patients with spontaneous bacterial peritonitis, the
addition of albumin infusion to antibiotics improves
survival compared with antibiotics alone [50]. In patients
with hepatorenal syndrome, the addition of albumin
infusion to the vasoconstrictor terlipressin improves
survival compared with terlipressin [51]. These data
emphasize both the safety and also the efficacy of albumin
in cirrhotic patients.
The present study was terminated 72 h after entry into
study, because it was designed to look at the pathophysiological mechanisms. This study can be criticized
because of its non-randomized design. The patients in the
HAS group were studied first and we were surprised at
the rapid improvement in the severity of HE. The patients
were recruited into the Colloid group to clarify whether
the effects of HAS were due to volume expansion alone
or to a non-oncotic property of albumin. Nevertheless,
we believe the results are important and robust given
that both groups of patients were well-matched for the
severity of the underlying liver disease and HE, the
degree of dehydration, their response to volume expansion, the reduction in circulating ammonia levels with
volume expansion and the increase in urinary ammonia
excretion.
In conclusion, the findings of our present study suggest
that volume expansion in patients with diuretic-induced
HE results in a significant reduction in plasma ammonia
levels due to increased renal ammonia excretion. The
significantly greater improvement in the severity of HE
in the HAS group compared with the Gelofusine® group
indicates either a positive effect of albumin or a negative
effect of Gelofusine® on the mental state. The association
of the greater improvement in the severity of HE in the
HAS group with the greater reduction in a marker of
oxidative stress supports the notion that protein-bound
substances, such as reactive oxygen species, are important
adjuncts to ammonia in the pathogenesis of diureticinduced HE and a possible role for HAS as the preferred
volume expander in the treatment of such patients. These
data advocate the need for a suitably powered randomized
controlled clinical trial, using albumin infusion as an
adjunct to conventional ammonia-lowering strategies in
HE.
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Received 3 November 2003; accepted 16 December 2003
Published as Immediate Publication 16 December 2003, DOI 10.1042/CS20030357
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