First observation of recovery of consciousness in hepatic coma

As shown in acute poisoning patients in the above section, adsorbent artificial cell hemoperfusion is effective in removing suicidal and accidental overdoses of medications in patients. It is also effective in removing other toxic substances from the circulating blood. Its effectiveness in removing hepatic toxins from the circulating blood was first shown in a grade IV hepatic coma patient, with recovery of consciousness within an hour after the initiation of hemoperfusion (Chang, 1972b).

A 50-year-old female was admitted with a history of alcohol abuse, onset of jaundice, fatigue, nausea, vomiting, and dark urine. There was no history of contact with hepatitis or of intravenous or intramuscular medication. On admission, she had spider nevi and ascites. The diagnosis was acute alcoholic hepatitis. Her condition deteriorated after admission and she became comatose and unresponsive. After remaining comatose for two days, her condition was considered as terminal and with the insistence of her relatives she was referred by her physician to me for possible hemoperfusion since nothing else could be done. One hour after hemoperfusion, she started to regain consciousness and began to recognize her relative and answer questions in sentences. Hemoperfusion was carried out for a total of 80 min. She remained conscious for about an hour after the end of the hemoperfusion, but lapsed into coma again. Three days later she was still comatose, and a second hemoperfusion was initiated. At the start of perfusion she was comatose; an hour later she looked at people when spoken to and there were increased voluntary movements and response to pain. She did not, however, recover full consciousness as in the first hemoperfusion. Shortly after this, a liver biopsy specimen showed cirrhosis, acute hepatitis, with small foci of regeneration. Thereafter, consciousness fluctuated between stupor and coma. A third hemoperfusion was carried out. Before this hemoperfusion, E.E.G. background activity was irregular and diffuse, with continuous theta and delta activity and occasional high-amplitude single slow-wave and rare complex biphasic or triphasic configurations. At this time, the patient was semi-comatose and did not respond to questions. An hour and a half after hemoperfusion the patient's consciousness improved and she started to answer questions; she also complained of thirst and heaviness in the leg. E.E.G. recording after hemoperfusion showed a minimum improvement in the background activity.

Biochemical evaluation of the treatment of hepatic coma was difficult, because the precise pathological mechanism was not known. On the other band, the three hemoperfusions each produced a clinical response in consciousness. In one case, when the E.E.G. was recorded there was a slight improvement in background activity. Since there was no change in the blood-ammonia level after hemoperfusion, we

Table 11. Hepatic Coma-related Chemicals Removed by Hemoperfusion

Aromatic branched chain amino acids Fatty acids — oleic, hexanoic, octanoic N-valeric Inhibitor of Na-K ATPase Inhibitor of hepatic regeneration Mercaptan Middle molecules Phenols

Protein bound molecules Others could not attribute the improvement in consciousness to the removal of blood-ammonia. However, whereas standard hemodialyzers at that time were not efficient in removing large molecules from blood, hemoperfusion was very efficient in removing molecules up to 5000 molecular weight (Chang, 1972e; Chang and Migchelsen, 1973; Chang and Lister, 1980; 1981) as well as protein bound molecules. Hemoperfusion is also effective in removing other chemicals related to hepatic coma (Table 11).

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