HYPONATREMIA IN HYPONATREMIA IN CIRRHOSIS OF LIVERCIRRHOSIS OF LIVER

Dr Rajesh KulkarniPune

DefinitionDefinitionSerum Sodium below 130mEq/L

(in patients with cirrhosis).

Why Important?Why Important?Increased risk of hepatic

encephalopathy.Increased risk of hepatorenal

syndromeIncreased mortality and poor

prognosisLiver transplant> Risk of CPM

Types of HyponatremiaTypes of Hyponatremia

HYPOVOLEMICHYPONATREMIA

HYPERVOLEMICHYPONATREMIA

CAUSESExcessive Diuretic use

Diarrhea

(Loss of fluid)

Marked impairment of renal solute-free water excretion, resulting in disproportionate renal retention of water with respect to sodium retention.

FEATURESLack of edema and ascites,

signs of dehydration present

Presence of ascites and edema

Management of hypovolemic Management of hypovolemic hyponatremia hyponatremia

Give Normal Saline

Stop Diuretics

Management of Management of hypervolemic hyponatremia hypervolemic hyponatremia (with ascites) (with ascites) Aim: Increase renal solute-free water

excretion

METHODS TO ACHIEVE METHODS TO ACHIEVE AIMAIMDietary Salt RestrictionFluid RestrictionDiuretics

(In adults V2 receptor antagonists like Satavaptan are being tried)

Dietary Salt RestrictionDietary Salt Restriction1 to 2mEq/kg/day for infants and

children

1 to 2 g/day (44 to 88 mEq of sodium/day) in adolescents.

Only 10 %of patients with ascites will respond to sodium restriction alone

Sodium Content of Indian Sodium Content of Indian FoodFoodItem Sodium(mEq)

Table Salt 1 gm 17

Aloo Sabji(1 bowl) 0.48

Paratha or Roti 0.22

Vegetable stuffed paratha 0.5 to 1

Cows milk(100 ml) 3.2

White Bread(1 slice) 6.7

Biscuit 6.1

Avoid Pickles, Papad,

Bakery products Burgers,Pizza Cheese Salted Peanuts

Taste kahan hai?

Look at other sources of Na e.g.IV antibiotics generally contain 2.1–3.6 mmol of sodium per gram

Fluid restrictionFluid restrictionEfficacy is limited

Difficult in children

Controversial even in adults

DiureticsDiureticsThe goal of diuresis is a negative

fluid balance of 10 cc/kg/day.

Single morning dose of spironolactone (0.3 to3 mg/kg) along with furosemide (0.5 to2 mg/kg) in the ratio of 5:2.

Dual therapy : Early mobilization of fluid with furosemide as spironolactone takes several days for a therapeutic response.

Dual diuretic therapy can be changed over to monotherapy with spironolactone alone while obtaining satisfactory diuretic response

Too Much of a good thingToo Much of a good thingOver diuresis is associated with

intravascular depletion , renal impairment, hepatic encephalopathy & hyponatremia

When to stop diuretics?When to stop diuretics?

Serum Na:121–125 mmol/l, serum creatinine elevated(>150 μmol/l or >120 μmol/l and rising)

Stop diuretics and give volume expansion (NS or Colloids: 5 %, 25 % albumin)

Take Home MessagesTake Home Messages

Hyponatremia is common in cirrhosis.

Important to distinguish hypovolemic vs hypervolemic hyponatremia.

Cornerstone of treatment is DiureticsSodium restriction has some roleWatch for complications of diuretic

use