From the Guidelines
The prognosis for someone with end-stage cirrhosis and hyperammonemia who is not responding to standard treatments like lactulose and rifaximin is generally poor, with survival typically ranging from days to a few months without effective intervention. At this advanced stage, when first-line treatments fail to control ammonia levels, mortality risk increases significantly 1. Alternative approaches may include adding other medications or considering liver transplantation if the patient is a candidate, though many may be too ill to qualify. The poor response to standard therapy indicates severe hepatic dysfunction and portosystemic shunting, where ammonia bypasses the damaged liver and accumulates in the bloodstream, causing hepatic encephalopathy and multiorgan dysfunction.
Key Considerations
- Addressing precipitating factors like infection, gastrointestinal bleeding, or dehydration is crucial 1.
- Patients at this stage should be evaluated for liver transplantation if they're candidates, as it significantly improves survival rates, with a 1-year survival rate of less than 25% without transplantation 2.
- Palliative care discussions are appropriate at this stage to manage symptoms and address end-of-life planning.
Management Strategies
- Continuous renal replacement therapy or albumin dialysis might be considered in hospital settings for severe cases 1.
- Adding other medications such as glycerol phenylbutyrate (Ravicti), branched-chain amino acids, or zinc supplementation may be beneficial.
- Referral to a liver transplant unit is recommended for patients with cirrhosis alive at discharge from ICU, given their poor prognosis without transplantation 2.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Prognosis of End-Stage Cirrhosis with Hyperammonia
- The prognosis for someone with end-stage cirrhosis and hyperammonia who isn't responding to lactulose and rifaximin is generally poor 3.
- Studies have shown that high ammonia levels are associated with increased mortality and organ failure in patients with cirrhosis 3.
- A study found that an ammonia level of ≥79.5 µmol/L was associated with a higher frequency of organ failures and higher mortality 3.
- Lack of improvement in baseline ammonia at day 5 was associated with high mortality (70.6%) 3.
Treatment Options
- Lactulose and rifaximin are the mainstay of treatment for hyperammonemia, but alternative treatments may be necessary for patients who do not respond to these medications 4.
- Sodium benzoate is an inexpensive adjunctive agent that can be used in addition to lactulose and rifaximin for patients with refractory HE 5.
- The molecular adsorbent recirculating system has been proven to be efficacious in patients with severe HE, but its mechanisms appear to be independent of ammonia 4.
Survival Time
- The survival time for someone with end-stage cirrhosis and hyperammonia who isn't responding to lactulose and rifaximin is difficult to predict, but studies suggest that high ammonia levels are associated with increased mortality 3.
- A study found that the 28-day mortality was 43.4% in patients with cirrhosis and acute decompensation, and ammonia level was an independent predictor of 28-day mortality 3.