Hepatic coma with renal failure, treated by repeated exchange transfusion.

Hepatic coma following acute hepatic necrosis carries a high mortality in spite of conventional therapy (Katz et al., 1962; McDonald and De la Harpe, 1963; Cook and Sherlock, 1965), but the concomitant development of renal failure makes the prognosis even worse (Hecker and Sherlock, 1956). Owing to the extraordinary capacity of the liver to regenerate, other forms of treatment have recently been tried in an endeavour to remove circulating 'toxic' substances, and allow time for regeneration to take place. These methods include exchange transfusion (Lee and Tink, 1958; Trey, Burns, and Saunders, 1966; Berger et al., 1966; Burnell et al., 1967; Jones et al., 1967), heterologous liver perfusion (Eiseman, Liem, and Raffucci, 1965; Eiseman, 1966), and human cross circulation (Burnell et al., 1965). Haemodialysis has not proved to be of any therapeutic benefit though a fall in blood ammonia levels may be achieved (Kiley, Pender, and Welch, 1958; Sherlock, 1961). Twenty-two cases treated by exchange transfusion have been reported. Considerable variation in the severity may account for the difference in the survival rate in these cases. In the original case and 4 of the 12 described by Trey and his colleagues, a dramatic and curative result followed a single exchange transfusion. However, in 5 other patients where severe renal failure was also present, all succumbed. Coma was alleviated in 14, but only 8 of the 22 patients survived, and in none of these was renal failure present. We describe the management of a 6-year-old child with progressive coma following multiple exposures to halothane anaesthesia. The cholaemia was complicated by severe renal failure, but recovery eventually occurred.