HRS, GI Bleed, SBP (?) HE and Ascites

[JSR2014]

Hi Guys,

Some of you might have seen my other posts - if not then a quick recap:

December my father becomes very ill, large tense ascites, Hepatic Encapathology and pre-existing cirrhosis. He quit drinking about 2 years ago. He was admitted to hospital (in December) and was suffering from AKI (Acute Kidney Injury/Kidney Failure). They managed to patch him up and he has been going for regular drains ever since.

The time between the drains has been getting ever shorter - when I say drain, they are large - between 14 and 20L.

I have noticed over the past few weeks a change in skin tone which I understand is not abnormal, that will be his billirubin levels rising.

So, anyway - back to my reason for posting!

He was admitted to hospital on Tuesday for some investigation as the HE was no longer being managed by the refraxamine (spelling?), suspected SBP and there were signs of a GI bleed (blood in underwear etc), whilst he was in the hospital he was to have his drain.

14 days ago (previous drain) he creatinine had dropped significantly, to below 70 which was an excellent result, INR was at 1.2 and stable.

Bloods were performed on Tuesday and his Creatinine has increased to over 200, he is back at AKI. The docs will not give us the full picture with regards blood results or GFR unfortunately so at this moment in time we do not know where we stand.

When speaking with the doctors yesterday, they advised that the results of the ascitic fluid draw appear to be negative for SBP, however they are still waiting for the blood cultures to confirm this catagorically. They have said that this can happen when someone is suffering from HRS.

Now, obviously when he was in AKI previously this was one of our major worries and looking at how quickly things have escalated I have come to the assumption that this is stage one, the bad one. I have based this on the following:

Little/No improvement in Creatinine levels after 1.5L of IV Saline

Little/No improvement in Creatinine levels after IV Glypressin (Terlipressin)

The extremely fast increase in the Creatinine levels

The "hand flap" test which the doctor performed

The fact that the HE is no longer being controlled (to the same extent) by the refraxamine.

He is 68 - the doctors have said that they'll try and get him on the emergency transplant list, any ideas how likely this is?

With all this in mind, does anyone have any idea or experience of what we can expect?

Thanks in advance.

[AyrshireK]

The last time you posted you said that doctors had sent his file to the transplant unit for consideration for assessment for transplant, he will need to be assessed by a transplant unit so they can see (a) how poorly his liver is ............... it's evident by his advanced symptoms and level of decompensated cirrhosis that this is becoming ever more urgent and (b) is he actually fit enough at 68 to undergo transplant and the lengthy recovery.  They will need to check his heart and lungs and also make sure he has not other health issues outside the liver which may make transplant an non-viable option.

It's all fine and well his current doctors saying they will get him on the emergency transplant list but they won't if he isn't being seen by a transplant unit as it is only they who can assess and list for transplant.  If he gets listed then it will be a case of waiting for a suitable organ - suitable means a blood type and size match for his body and also what type of donor organ is suitable (some folks will get from a brain deceased donor, some from a cardiac deceased donor and some smaller adults might also be able to accept a split liver or a portion of a liver from a living donor).  HE NEEDS AN URGENT LIVER TRANSPLANT ASSESSMENT AND LISTING or sadly judging by his issues I hate to say it he will probably not make it.

Make sure an assessment for transplant is forthcoming ASAP.

WIshing you all the very, very best at this sad time, Katie xx

[JSR2014 in reply to AyrshireK]

Hi Katie,

I will keep this brief as I am on a train from London.

I can confirm that he has an appointment for transplant assessment at the end of this month.

He appears to be improving in the hospital, however he has had to have 2 units of blood (transfusion) due to the GI bleed, he is having scopes (at both ends) in the coming days and they hope to find the source of the bleed.

His bloods have now improved, Creatinine down to 150ish although INR increased to 1.3

They are putting this down to a stomach infection which caused Kidney Failure even though his stomach was not bad prior to admission which I find curious, the concern is that something as trivial as this can put him in kidney failure.

I tend to agree that the chances of being granted a liver are low, and the chances of him making it until such a time that one is available, even lower.

His heart and lungs are apparently sound, its the kidneys and of course Liver where the issues are apparent.

Its an awful time - any more thoughts/advice would be greatly appreciated.