Abstract
Essential amino acid (EAA) therapy has been reported to correct the shortcomings of low-protein diet therapy in renal failure patients. We experienced two dialysis patients with refractory ascites who became delirious after a few days of arginine-free EAA hyperalimentation. Patient 1 was a 54-year-old man with a 5-year-history of hemodialysis for chronic glomerulonephritis. Consciousness disturbance occurred after eight days of EAA therapy. Patient 2 was a 38-year-old woman with Wegener's granulomatosis and a 4-year-history of continuous ambulatory peritoneal dialysis (CAPD). The consciousness disorder occurred after two days of EAA therapy in a similar manner. Both of these patients developed their consciousness disturbance after EAA hyperalimentation and recovered after treatment with branched chain-amino acids (BCAAs), suggesting that consciousness disturbance in these patients is due to hepatic encephalopathy, in spite of the absence of data suggestive of liver cirrhosis. At the time of the consciousness disturbance, the patients were hypoproteinemic and suffering from refractory ascites of unknown etiology, and the consciousness disturbance was probably associated with removal of the ascites. The pathologic findings observed in the liver at autopsy were consistent with chronic hepatitis. Based on this evidence, we suspected that in the presence of decreased plasma volume and decreased hepatic plasma flow due to hypoproteinemia and ascites, the hepatic encephalopathy might have been triggered by aromatic amino acid-rich EAA therapy in spite of the absence of any direct evidence of cirrhosis of the liver, and worsened by the removal of the ascites which may have caused a greater reduction in plasma volume and hepatic plasma flow.
