Complex Interplay of Cardiac, Hepatic, and Renal Dysfunction in a Patient with Extra-hepatic Portal Vein Obstruction and Rheumatic Mitral Stenosis: A Case Report

Abstract

This case report presents a 31-year-old male with a complex interplay of cardiac, hepatic, and renal dysfunction, characterized by extra-hepatic portal venous obstruction (EHPVO), decompensated chronic liver disease (DCLD), and rheumatic heart disease (RHD) with severe mitral stenosis. The patient exhibited altered sensorium and hemodynamic instability, reflecting the intricate relationship between the heart, liver, and kidneys, often referred to as the cardio-hepato-renal axis. The initial presentation included hepatic encephalopathy, ascites, and acute kidney injury, highlighting the challenges in managing multi-organ dysfunction. EHPVO, resulting from portal vein thrombosis, led to chronic portal hypertension and subsequent liver dysfunction, while RHD with mitral stenosis exacerbated cardiac strain and reduced renal perfusion. The clinical examination revealed significant cardiovascular findings, including elevated left atrial pressure, which contributed to pulmonary congestion and further impacted renal function. Laboratory tests indicated elevated bilirubin levels, coagulopathy, and renal impairment, consistent with the diagnosis of hepatic encephalopathy and acute kidney injury. Management strategies included pharmacotherapy aimed at addressing hepatic encephalopathy and portal hypertension, such as lactulose and non-selective beta-blockers, along with diuretics to manage ascites. Renal support was considered to maintain adequate perfusion in light of the patient’s hemodynamic instability. This case underscores the importance of a holistic and multi-disciplinary approach in managing patients with concurrent cardiac, hepatic, and renal dysfunctions, emphasizing the need for integrated strategies to address the complexities of such presentations. Through this report, we aim to enhance understanding of the interdependencies between these organ systems and provide insights into the clinical management of complex cases involving multi-organ dysfunction.