Author: Shardule Nanavati, MD; Richard Goodgame, MDSeries Editor: Richard Goodgame, MD

Disclosures

January 09, 2004

Case Presentation

A 64-year-old man with progressive renal failure after hepatic resection presented to clinic. (The events discussed below -- and the patient's eventual death -- occurred in 2002).

The patient had a history of chronic hepatitis C infection. As part of a screening program, he was found to have an increased alpha fetoprotein level (> 1900 ng/mL) and a 4 cm x 4 cm mass on magnetic resonance imaging (MRI) consistent with hepatocellular carcinoma (HCC). The patient underwent an exploratory laparotomy that revealed cirrhosis, the tumor, and no evidence of extrahepatic disease or portal adenopathy. An intraoperative ultrasound showed the mass to be limited to the right lobe of the liver. Segments 5 and 6, and a part of segment 7, were resected. Frozen sections showed HCC and clear margins. The patient tolerated the procedure well. On postoperative day 4 he became encephalopathic with an acute rise in ammonia levels. The international normalized ratio increased to > 3. On postoperative day 14 he had a gastrointestinal hemorrhage from gastric erosions. He then developed respiratory distress and was intubated. The patient received standard supportive care but no nephrotoxic drugs. He was hemodynamically stable. His mental status remained poor, with grade 3 encephalopathy. His renal function began a progressive decline on postoperative day 19 (see below).

His past medical history was positive for intravenous drug use and psoriasis. Hepatitis C infection was diagnosed 8 years prior to this presentation. Postoperative medications included propranolol, octreotide, pantoprazole, piperacillin/tazobactam, and lactulose. There was no prior history of cardiac, pulmonary, or renal disease. There was no family history of liver disease.

Physical examination (surgical intensive care unit -- postoperative day 14) revealed normal vital signs. He had diffuse edema (anasarca) and obvious ascites. There was deep jaundice. There were no other stigmata of chronic liver disease. There was jugular venous distension. The heart was normal to palpation and auscultation. The lung examination was normal. The abdomen was distended with fluid. Mental status showed grade 3 encephalopathy. Results of laboratory studies are shown in Table 1 .

On postoperative day 19, urine microscopy revealed rare red blood cells and white blood cells. Urine output on postoperative days 19, 22, and 24 was 20, 15, and 12 mL/hour, respectively. On postoperative day 19, urinalysis revealed trace amounts of protein and a sodium level of 7 mEq/L; results of renal ultrasound were normal.

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