Deep hyperammonemic hepatic encephalopathy precipitated by fecal microbiota transplantation for fulminant Clostridioides difficile infection

Introduction Fecal microbiota transplantation(FMT)is highly effective and potentially life-saving for recurrent Clostridioides difficile infection(CDI)[1].Recent pilot trials also reported the use of FMT to revert hepatic encephalopathy(HE)in patients with decompensated liver cirrhosis without infectious colitis[2,3].Intestinal microbiota-driven hyperammonemia is central to HE development and most treatments aim to reduce ammonia levels by modulating the intestinal microbiota.However,FMT might lead to increased intestinal ammonia production,as we describe here.