|
1
|
Rajakumar A, Paulin S, Sam AF, Jothimani D, Rammohan A, Rela M. Impact of Perioperative Serum Sodium Levels on Outcomes Following Living Donor Liver Transplantation. J Clin Exp Hepatol 2025; 15:102511. [PMID: 40093507 PMCID: PMC11908579 DOI: 10.1016/j.jceh.2025.102511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Accepted: 01/29/2025] [Indexed: 03/19/2025] Open
Abstract
Background & objectives Preoperative hyponatremia has been shown to be associated with poor outcomes post-liver transplantation. We analyzed the impact of preoperative hyponatremia and perioperative sodium (Na) changes on outcomes following adult living donor liver transplantation. Methods After obtaining clearance from Institutional ethical Committee, a retrospective review of electronic database and medical records of all adult patients who underwent LDLT between January 2019 and September 2022 was done and relevant perioperative data were collected. Results The study cohort of 520 recipients was divided into four groups based on preoperative serum Na levels in mmol/L; 12 patients (2.3%) in Group A (<125); 66 patients (12.6%) in Group B (125-129); 216 patients (41.5%) in Group C (130-135) and 226 patients (43.4%) in Group D (136-145). MELD score, preoperative AKI, SBP, intraoperative ascites volume, volume of packed blood cells (PRC), other blood products and 25% albumin were significantly associated with the degree of hyponatremia. No other outcomes including mortality was associated any grade of hyponatremia. The delta sodium on postoperative day 1 was largest in Group A. The level of Na rise post-transplant on POD1 had an inverse correlation with preoperative Na levels [ r (520) -0.6, P < 0.001]. High delta sodium was not associated with neurological complications in this cohort. Group A patients had higher incidence of postoperative AKI requiring dialysis followed by groups B, C and D. Eighty-six (16.5%) patients had large delta-Na of >10 mmol/L. On univariate analysis, low pretransplant Na (<130mEq/L), preoperative AKI, SBP, higher MELD and ascitic volumes, intraoperative transfusions of PRC, blood products and 25% albumin, early allograft dysfunction and need for dialysis, were associated with larger delta-Na. On multivariate analysis, preoperative Na levels ≤130 mmol/L, intraoperative ascites and PRC transfusion were found to be independent risk factors for a large delta-Na. Conclusion Hyponatremia, being a factor associated with liver disease, might not by itself contribute to poor survival when the deleterious effects of large delta changes can be avoided. The results from this study reinforces the fact that with a cautious perioperative approach, patients with hyponatremia can be transplanted safely in LDLT settings.
Collapse
Affiliation(s)
- Akila Rajakumar
- Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Susan Paulin
- Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Amal Francis Sam
- Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Dinesh Jothimani
- Department of Hepatology and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Ashwin Rammohan
- Department of HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mohamed Rela
- Department of HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| |
Collapse
|
|
2
|
McDaniel CC, Lo-Ciganic WH, Chou C. Diabetes-related complications, glycemic levels, and healthcare utilization outcomes after therapeutic inertia in type 2 diabetes mellitus. Prim Care Diabetes 2024; 18:188-195. [PMID: 38185576 DOI: 10.1016/j.pcd.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
AIMS To assess diabetes-related complications, glycemic levels, and healthcare utilization 12 months after exposure to therapeutic inertia among patients with type 2 diabetes mellitus (T2D). METHODS This retrospective cohort study analyzed data from the OneFlorida Clinical Research Consortium (electronic health records from Florida practices/clinics). The cohort included adult patients (≥18 years old) with T2D who had an HbA1c≥7.0% (53 mmol/mol) recorded from January 1, 2014-September 30, 2019. Therapeutic inertia (exposed vs. not exposed) was evaluated during the six months following HbA1c≥7.0% (53 mmol/mol). The outcomes assessed during the 12-month follow-up period included diabetes-related complications (continuous Diabetes Complications and Severity Index (DCSI)), glycemic levels (continuous follow-up HbA1c lab), and healthcare utilization counts. We analyzed data using multivariable regression models, adjusting for covariates. RESULTS The cohort included 26,881 patients with T2D (58.94% White race, 49.72% female, and mean age of 58.82 (SD=13.09)). After adjusting for covariates, therapeutic inertia exposure was associated with lower DCSI (estimate=-0.14 (SE=0.03), p < 0.001), higher follow-up HbA1c (estimate=0.14 (SE=0.04), p < 0.001), and lower rates of ambulatory visits (rate ratio=0.79, 95% CI=0.75-0.82). CONCLUSIONS Findings communicate the clinical practice implications and public health implications for combating therapeutic inertia in diabetes care.
Collapse
Affiliation(s)
- Cassidi C McDaniel
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA.
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA; North Florida/South Georgia Veterans Health System, Geriatric Research Education and Clinical Center, Gainesville, FL, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA; Department of Medical Research, China Medical University Hospital, Taichung City, Taiwan
| |
Collapse
|
|
3
|
Yau AA, Buchkremer F. Hyponatremia in the Context of Liver Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:139-146. [PMID: 38649218 DOI: 10.1053/j.akdh.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/22/2023] [Accepted: 12/15/2023] [Indexed: 04/25/2024]
Abstract
Hyponatremia is common in patients with liver disease and is associated with increased mortality, morbidity, and a reduced quality of life. In liver transplantation, the inclusion of hyponatremia in organ allocation scores has reduced waitlist mortality. Portal hypertension and the resulting lowering of the effective arterial blood volume are important pathogenetic factors, but in most patients with liver disease, hyponatremia is multifactorial. Treatment requires a multifaceted approach that tries to reduce electrolyte-free water intake, restore urinary dilution, and increase nonelectrolyte solute excretion. Albumin therapy for hyponatremia is a peculiarity of advanced liver disease. Its use appears to be increasing, while the vaptans are currently only given in selected cases. Osmotic demyelination is a special concern in patients with liver disease. Serial checks of serum sodium concentrations and urine volume monitoring are mandatory.
Collapse
Affiliation(s)
- Amy A Yau
- Division of Nephrology, The Ohio State University, Columbus, OH
| | | |
Collapse
|
|
4
|
Ryu JY, Baek SH, Kim S. Evidence-based hyponatremia management in liver disease. Clin Mol Hepatol 2023; 29:924-944. [PMID: 37280091 PMCID: PMC10577348 DOI: 10.3350/cmh.2023.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 06/08/2023] Open
Abstract
Hyponatremia is primarily a water balance disorder associated with high morbidity and mortality. The pathophysiological mechanisms behind hyponatremia are multifactorial, and diagnosing and treating this disorder remains challenging. In this review, the classification, pathogenesis, and step-by-step management approaches for hyponatremia in patients with liver disease are described based on recent evidence. We summarize the five sequential steps of the traditional diagnostic approach: 1) confirm true hypotonic hyponatremia, 2) assess the severity of hyponatremia symptoms, 3) measure urine osmolality, 4) classify hyponatremia based on the urine sodium concentration and extracellular fluid status, and 5) rule out any coexisting endocrine disorder and renal failure. Distinct treatment strategies for hyponatremia in liver disease should be applied according to the symptoms, duration, and etiology of disease. Symptomatic hyponatremia requires immediate correction with 3% saline. Asymptomatic chronic hyponatremia in liver disease is prevalent and treatment plans should be individualized based on diagnosis. Treatment options for correcting hyponatremia in advanced liver disease may include water restriction; hypokalemia correction; and administration of vasopressin antagonists, albumin, and 3% saline. Safety concerns for patients with liver disease include a higher risk of osmotic demyelination syndrome.
Collapse
Affiliation(s)
- Ji Young Ryu
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul University Bundang Hospital, Seongnam, Korea
- Center for Artificial Intelligence in Healthcare, Seoul University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
|
5
|
Matsumi S, Kimura SI, Nakamura Y, Kawamura M, Takeshita J, Kawamura S, Yoshino N, Misaki Y, Yoshimura K, Gomyo A, Okada Y, Akahoshi Y, Tamaki M, Kusuda M, Kameda K, Wada H, Tanihara A, Sato M, Nakasone H, Kako S, Kanda Y. Substitution of calcineurin inhibitors with corticosteroids after allogeneic hematopoietic cell transplantation. Int J Hematol 2023; 118:450-461. [PMID: 37480446 DOI: 10.1007/s12185-023-03645-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023]
Abstract
Combination of calcineurin inhibitors (CIs) with short-term methotrexate is a standard prophylactic regimen for graft-versus-host disease (GVHD). However, it is sometimes difficult to continue CIs due to adverse effects, such as renal impairment and fluid overload. In such cases, we replace CIs with corticosteroids, considering that full dose of CIs is equivalent to prednisolone (PSL) at 1 mg/kg. We retrospectively evaluated the clinical significance of replacement of CIs with corticosteroids after allogeneic hematopoietic cell transplantation (HCT). We evaluated 42 patients switched from CIs to corticosteroids within 90 days among the 479 patients who underwent allogeneic HCT at our center between 2007 and 2019. Renal impairment (n = 33), fluid overload (n = 13), and thrombotic microangiopathy (n = 3) were the main reasons for switching. Although creatinine and body weight returned to baseline at 4 weeks after switching, 100-day non-relapse mortality was high (57.1%). Grade II-IV acute GVHD was seen in 10 (24.4%) patients who did not have it before switching treatment (n = 41). In conclusion, CIs were switched to corticosteroids in patients with severe clinical conditions. The incidence of acute GVHD was acceptable. Although the short-term mortality rate was high, improvement of renal function or fluid overload was observed in a certain proportion of the patients.
Collapse
Affiliation(s)
- Shimpei Matsumi
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yuhei Nakamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Masakatsu Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Junko Takeshita
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Shunto Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Nozomu Yoshino
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Kazuki Yoshimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Ayumi Gomyo
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yosuke Okada
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Machiko Kusuda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Kazuaki Kameda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Hidenori Wada
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Aki Tanihara
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Miki Sato
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan.
| |
Collapse
|
|
6
|
Luglio M, de Carvalho WB, Tannuri U, Tannuri ACA, Matsura RH, Morais França G, Delgado AF. Effects of serum sodium and chloride levels in the outcome of critically ill pediatric patients in the post-operative period of liver transplantation. BMC Nephrol 2023; 24:141. [PMID: 37217877 DOI: 10.1186/s12882-023-03195-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Sodium and chloride disturbances have attracted increasing attention in recent years. Many pathophysiological effects are associated with hyperchloremia, including reduction in mean arterial pressure and acute renal disease. Pediatric patients undergoing liver transplantation are at risk of developing various electrolyte and biochemical abnormalities, with an impact on their postoperative outcomes. OBJECTIVE To analyze the impacts of serum sodium and chloride levels on prognosis of Pediatric Liver Transplant receptors. METHODS This was a retrospective analytical observational study performed in a single transplant reference center in Sao Paulo, Brazil. Included patients were pediatric patients who underwent liver transplantation between January 2015 and July 2019. Statistical regression analysis and General Estimating Equations analysis were performed to evaluate the impacts of sodium and chloride disturbances on the development of acute renal failure and mortality. RESULTS A total of 143 patients were included in this study. The main diagnosis was Biliary Atresia (62.9%). Twenty-seven patients died (18.9%), and graft dysfunction was the main cause of death (29.6%). The only variable individually associated with 28-days mortality was PIM-3 score (HR 1.59, CI 95% 1.165-2.177, p = 0.004). Forty-one patients (28.6%) developed moderate or severe AKI. PIM-3 score (OR 3.052, 95% CI 1.56-5.97, p = 0.001), hypernatremia (OR 3.49, 95% CI 1.32-9.23, p = 0.012), and hyponatremia (OR 4.24, 95% CI 1.52-11.85, p = 0.006) were independently associated with the development of moderate/severe AKI. CONCLUSIONS In pediatric patients after liver transplantation, PIM-3 score, and abnormal serum sodium levels were correlated with AKI development.
Collapse
Affiliation(s)
- Michele Luglio
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Werther B de Carvalho
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Uenis Tannuri
- Pediatric Surgery and Liver Transplant Team, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ana Cristina A Tannuri
- Pediatric Surgery and Liver Transplant Team, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Hideki Matsura
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gardenia Morais França
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Artur F Delgado
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
|
7
|
Teo CB, Gan MY, Tay RYK, Loh WJ, Loh NHW. Association of preoperative hyponatremia with surgical outcomes: a systematic review and meta-analysis of 32 observational studies. J Clin Endocrinol Metab 2022; 108:1254-1271. [PMID: 36472931 PMCID: PMC10099166 DOI: 10.1210/clinem/dgac685] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative hyponatremia is prevalent in patients undergoing surgical procedures, but it is uncertain if hyponatremia will lead to increased risk of surgical mortality and morbidity. METHODS A systematic search of Medline (PubMed), Embase and Cochrane Library from inception till 2 July 2021 was performed. Full length articles that reported on the association between surgical outcomes among adults ≥18 years with documented preoperative hyponatremia were included. FINDINGS We identified 32 observational studies comprising 1,301,346 participants. All studies had low risk of bias. When adjusted for covariates, patients with hyponatremia had significantly higher odds of developing major complications (defined as a composite measure of 9 major complications) compared to patients with normal sodium concentrations (aOR = 1.37, 95%CI = 1.23-1.53, I2 = 78%. N = 10). Additionally, patients with preoperative hyponatremia also significantly higher hazards of early mortality (<90 days) compared to patients with normonatremia (aHR = 1.27, 95%CI = 1.13-1.43, I2 = 97%. N = 10) after adjustment for covariates. Preoperative hyponatremia also had significant associations with respiratory, renal and septic complications. In terms of prognostic performance, preoperative hyponatremia performed adequately in predicting major complications in surgical patients (AUC = 0.70, LR- 0.90) with a specificity of 88% and a sensitivity of 25%. INTERPRETATION Our meta-analysis suggests that preoperative hyponatremia is associated with poorer early mortality and major morbidity outcomes in surgical patients. Hyponatremia is also a specific prognosticator for major complications in surgical patients, reiterating its potential use as a clinical indicator of poor outcomes.
Collapse
Affiliation(s)
- Chong Boon Teo
- Ministry of Health Holdings, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Ne-Hooi Will Loh
- Department of Anaesthesia, National University Hospital, Singapore
| |
Collapse
|
|
8
|
Abstract
Hyponatremia is the most common electrolyte disorder encountered in clinical practice, and it is a common complication of cirrhosis reflecting an increase in nonosmotic secretion of arginine vasopressin as a result of of the circulatory dysfunction that is characteristic of advanced liver disease. Hyponatremia in cirrhosis has been associated with poor clinical outcomes including increased risk of morbidity and mortality, poor quality of life, and heightened health care utilization. Despite this, the treatment of hyponatremia in cirrhosis remains challenging as conventional therapies such as fluid restriction are frequently ineffective. In this review, we discuss the epidemiology, clinical outcomes, pathogenesis, etiology, evaluation, and management of hyponatremia in cirrhosis.
Collapse
Affiliation(s)
- Helbert Rondon-Berrios
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Q. Velez
- Ochsner Clinical School/The University of Queensland, Brisbane, Queensland, Australia AND Department of Nephrology, Ochsner Health, New Orleans, Louisiana, USA
| |
Collapse
|
|
9
|
Verbeek TA, Saner FH, Bezinover D. Hyponatremia and Liver Transplantation: A Narrative Review. J Cardiothorac Vasc Anesth 2022; 36:1458-1466. [PMID: 34144870 DOI: 10.1053/j.jvca.2021.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 11/11/2022]
Abstract
Hyponatremia is a common electrolyte disorder in patients with end-stage liver disease (ESLD) and is associated with increased mortality on the liver transplantation (LT) waiting list. The impact of hyponatremia on outcomes after LT is unclear. Ninety-day and one-year mortality may be increased, but the data are conflicting. Hyponatremic patients have an increased rate of complications and longer hospital stays after transplant. Although rare, osmotic demyelination syndrome (ODS) is a feared complication after LT in the hyponatremic patient. The condition may occur when the serum sodium (sNa) concentration increases excessively during or after LT. This increase in sNa concentration correlates with the degree of preoperative hyponatremia, the amount of intraoperative blood loss, and the volume of intravenous fluid administration. The risk of developing ODS after LT can be mitigated by avoiding large perioperative increases in sNa concentration . This can be achieved through measures such as carefully increasing the sNa pretransplant, and by limiting the intravenous intra- and postoperative amounts of sodium infused. SNa concentrations should be monitored regularly throughout the entire perioperative period.
Collapse
Affiliation(s)
- Thomas A Verbeek
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA.
| | - Fuat H Saner
- Department of General, Visceral, and Transplantation Surgery, Essen University Medical Center, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA
| |
Collapse
|
|
10
|
Praharaj DL, Anand AC. Clinical Implications, Evaluation, and Management of Hyponatremia in Cirrhosis. J Clin Exp Hepatol 2022; 12:575-594. [PMID: 35535075 PMCID: PMC9077240 DOI: 10.1016/j.jceh.2021.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is the most common electrolyte abnormality in patients with decompensated cirrhosis on Liver Transplantation (LT) waiting list. Most of these patients have dilutional or hypervolemic hyponatremia secondary to splanchnic vasodilatation. Excessive secretion of the antidiuretic hormone also plays an important role. Hypervolemic hyponatremia is commonly associated with refractory ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy. Although uncommon, the use of diuretics and laxatives can cause hypovolemic hyponatremia that is characterized by the striking absence of ascites or pedal edema. Clinical features are often nonspecific and depend on the acuity of onset rather than the absolute value of serum sodium. Symptoms may be subtle, including nausea, lethargy, weakness, or anorexia. However, rarely patients may present with confusion, seizures, psychosis, or coma. Treatment includes discontinuation of diuretics, beta-blockers, and albumin infusion. Hypertonic saline (3%) infusion may be used in patients with very low serum sodium (<110 mmol/L) or when patients present with seizures or coma. Short-term use of Vasopressin (V2) receptor antagonists may also be used to normalize sodium levels prior to LT. However, all these measures may be futile, and LT remains the definite treatment in these patients to improve survival. In this review, we describe the classification, pathogenesis of hyponatremia, and its clinical implications in patients with cirrhosis. Approach to these patients along with management will also be discussed briefly.
Collapse
Key Words
- ACE, angiotensin-converting enzyme
- ACLF, acute-on-chronic liver failure
- ACTH, adrenocorticotropic hormone
- ADH
- ADH, antidiuretic hormone
- AKI, acute kidney injury
- AVP, arginine vasopressin
- CLIF, chronic liver failure
- CNS, central nervous system
- CTP, Child-Turcotte-Pugh
- CVVHD, continuous venovenous hemofiltration
- DAMP, damage-associated molecular patterns
- EABV, effective arterial blood volume
- FENa, fractional excretion of sodium
- HE, hepatic encephalopathy
- HRS, hepatorenal syndrome
- LT, liver transplantation
- LVP, large volume paracentesis
- MAP, mean arterial pressure
- MELD, model of end-stage liver disease
- NO, nitric oxide
- NSBB, nonselective beta-blockers
- PAMP, pathogen-associated molecular patterns
- PICD, paracentesis-induced circulatory dysfunction
- PPCD, post-paracentesis circulatory dysfunction
- PRA, plasma renin activity
- RA, refractory ascites
- RAAS, renin-angiotensin-aldosterone-system
- RAI, relative adrenal insufficiency
- RBF, renal blood flow
- SBP, spontaneous bacterial peritonitis
- SIADH, syndrome of inappropriate ADH secretion
- SMT, standard medical treatment
- SNS, sympathetic nervous system
- TBW, total body water
- TIPS, transjugular intrahepatic portosystemic shunt
- advanced cirrhosis
- albumin
- hyponatremia
- liver transplantation
- sNa, serum sodium
Collapse
Affiliation(s)
- Dibya L. Praharaj
- Address for correspondence. Dibya L Praharaj, Assistant Professor, Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Science, Bhubaneswar, India
| | | |
Collapse
|
|
11
|
McDaniel CC, Chou C. Clinical risk factors and social needs of 30-day readmission among patients with diabetes: A retrospective study of the Deep South. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:1050579. [PMID: 36992731 PMCID: PMC10012098 DOI: 10.3389/fcdhc.2022.1050579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 03/31/2023]
Abstract
Introduction Evidence is needed for 30-day readmission risk factors (clinical factors and social needs) among patients with diabetes in the Deep South. To address this need, our objectives were to identify risk factors associated with 30-day readmissions among this population and determine the added predictive value of considering social needs. Methods This retrospective cohort study utilized electronic health records from an urban health system in the Southeastern U.S. The unit of analysis was index hospitalization with a 30-day washout period. The index hospitalizations were preceded by a 6-month pre-index period to capture risk factors (including social needs), and hospitalizations were followed 30 days post-discharge to evaluate all-cause readmissions (1=readmission; 0=no readmission). We performed unadjusted (chi-square and student's t-test, where applicable) and adjusted analyses (multiple logistic regression) to predict 30-day readmissions. Results A total of 26,332 adults were retained in the study population. Eligible patients contributed a total of 42,126 index hospitalizations, and the readmission rate was 15.21%. Risk factors associated with 30-day readmissions included demographics (e.g., age, race/ethnicity, insurance), characteristics of hospitalizations (e.g., admission type, discharge status, length of stay), labs and vitals (e.g., highest and lowest blood glucose measurements, systolic and diastolic blood pressure), co-existing chronic conditions, and preadmission antihyperglycemic medication use. In univariate analyses of social needs, activities of daily living (p<0.001), alcohol use (p<0.001), substance use (p=0.002), smoking/tobacco use (p<0.001), employment status (p<0.001), housing stability (p<0.001), and social support (p=0.043) were significantly associated with readmission status. In the sensitivity analysis, former alcohol use was significantly associated with higher odds of readmission compared to no alcohol use [aOR (95% CI): 1.121 (1.008-1.247)]. Conclusions Clinical assessment of readmission risk in the Deep South should consider patients' demographics, characteristics of hospitalizations, labs, vitals, co-existing chronic conditions, preadmission antihyperglycemic medication use, and social need (i.e., former alcohol use). Factors associated with readmission risk can help pharmacists and other healthcare providers identify high-risk patient groups for all-cause 30-day readmissions during transitions of care. Further research is needed about the influence of social needs on readmissions among populations with diabetes to understand the potential clinical utility of incorporating social needs into clinical services.
Collapse
Affiliation(s)
- Cassidi C. McDaniel
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, United States
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, United States
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- *Correspondence: Chiahung Chou,
| |
Collapse
|
|
12
|
Mahiliavets EV, Bozhko YN, Mahiliavets ON. Use of laparocentesis in the treatment of ascites in patients with liver cirrhosis. PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF BELARUS, MEDICAL SERIES 2021; 18:362-374. [DOI: 10.29235/1814-6023-2021-18-3-362-374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Ascites occurs in about 60 % of patients with cirrhosis within 10 years of diagnosis. Laparocentesis is the preferred first-line therapy in patients with cirrhosis and massive tense ascites, allowing more than 5–6 liters of ascitic fluid to be removed at one time. The search for informative prognostic factors and the development of a method for predicting unfavorable outcomes of repeated laparocenteses in patients with ascites are relevant to timely refer this contingent of patients to perform TIPS.The purpose of the study was to develop and evaluate the diagnostic significance of a model for determining the probability of unfavorable outcomes of laparocentesis in patients with ascites on the background of liver cirrhosis.The results of treatment of 99 patients with the ascitic syndrome associated with intrahepatic portal hypertension were studied. The multiple regression analysis using the binary response logit model was carried out to calculate the prediction models. The analysis of the treatment results of patients with liver cirrhosis and ascites by the laparocentesis method revealed a number of factors that influence the onset of an unfavorable outcome. 2 models with the inclusion of initial variables are the most promising for forecasting. Model A includes: patient weight, serum-ascites total protein gradient, hyponatremia; model B: MELD-Na score, serum-ascitic total protein gradient, patient weight. The developed prediction method is highly informative, effective, easily applicable, and can be widely used in clinical practice.The ability to predict an unfavorable outcome in patients with portal hypertension and ascites after laparocentesis allows for a personalized approach in the process of timely selection of more effective, but also more expensive treatment methods, such as TIPS, which will help us to increase the therapy effectiveness and the survival of this cohort of patients.
Collapse
|
|
13
|
Ala M, Mohammad Jafari R, Hajiabbasi A, Dehpour AR. Aquaporins and diseases pathogenesis: From trivial to undeniable involvements, a disease-based point of view. J Cell Physiol 2021; 236:6115-6135. [PMID: 33559160 DOI: 10.1002/jcp.30318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/01/2023]
Abstract
Aquaporins (AQPs), as transmembrane proteins, were primarily identified as water channels with the ability of regulating the transmission of water, glycerol, urea, and other small-sized molecules. The classic view of AQPs involvement in therapeutic plan restricted them and their regulators into managing only a narrow spectrum of the diseases such as diabetes insipidus and the syndrome of inappropriate ADH secretion. However, further investigations performed, especially in the third millennium, has found that their cooperation in water transmission control can be manipulated to handle other burden-imposing diseases such as cirrhosis, heart failure, Meniere's disease, cancer, bullous pemphigoid, eczema, and Sjögren's syndrome.
Collapse
Affiliation(s)
- Moein Ala
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Razieh Mohammad Jafari
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Asghar Hajiabbasi
- Guilan Rheumatology Research Center, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Ahmad Reza Dehpour
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
|
14
|
Berchtold L, Filzer A, Achermann R, Devetzis V, Dahdal S, Bonani M, Schnyder A, Golshayan D, Amico P, Huynh-Do U, de Seigneux S, Arampatzis S. Impact of Hyponatremia after Renal Transplantation on Decline of Renal Function, Graft Loss and Patient Survival: A Prospective Cohort Study. Nutrients 2021; 13:nu13092995. [PMID: 34578871 PMCID: PMC8468476 DOI: 10.3390/nu13092995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/19/2021] [Accepted: 08/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Hyponatremia is one of the most common electrolyte disorders observed in hospitalized and ambulatory patients. Hyponatremia is associated with increased falls, fractures, prolonged hospitalisation and mortality. The clinical importance of hyponatremia in the renal transplant field is not well established, so the aim of this study was to determine the relationships between hyponatremia and mortality as main outcome and renal function decline and graft loss as secondary outcome among a prospective cohort of renal transplant recipients. Methods: This prospective cohort study included 1315 patients between 1 May 2008 and 31 December 2014. Hyponatremia was defined as sodium concentration below 136 mmol/L at 6 months after transplantation. The main endpoint was mortality. A secondary composite endpoint was also defined as: rapid decline in renal function (≥5 mL/min/1.73 m2 drop of the eGFR/year), graft loss or mortality. Results: Mean sodium was 140 ± 3.08 mmol/L. 97 patients displayed hyponatremia with a mean of 132.9 ± 3.05 mmol/L. Hyponatremia at 6 months after transplantation was associated neither with mortality (HR: 1.02; p = 0.97, 95% CI: 0.47–2.19), nor with the composite outcome defined as rapid decline in renal function, graft loss or mortality (logrank test p = 0.9). Conclusions: Hyponatremia 6 months after transplantation is not associated with mortality in kidney allograft patients.
Collapse
Affiliation(s)
- Lena Berchtold
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, 1205 Geneva, Switzerland; (L.B.); (S.d.S.)
| | - Anja Filzer
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Rita Achermann
- Department of Transplant Immunology and Nephrology, University Hospital Basel, 4031 Basel, Switzerland; (R.A.); (P.A.)
| | - Vasileios Devetzis
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Suzan Dahdal
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Marco Bonani
- Division of Nephrology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Aurelia Schnyder
- Clinic for Nephrology and Transplant Medicine, Hospital of St. Gallen, 9007 St. Gallen, Switzerland;
| | - Dela Golshayan
- Centre for Organ Transplantation (CTO), 1011 Lausanne, Switzerland;
| | - Patrizia Amico
- Department of Transplant Immunology and Nephrology, University Hospital Basel, 4031 Basel, Switzerland; (R.A.); (P.A.)
| | - Uyen Huynh-Do
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Sophie de Seigneux
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, 1205 Geneva, Switzerland; (L.B.); (S.d.S.)
| | - Spyridon Arampatzis
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
- Correspondence: ; Tel.: +41-31-632-3111
| | | |
Collapse
|
|
15
|
Zamberg I, Maillard J, Assouline B, Tomala S, Keli-Barcelos G, Aldenkortt F, Mavrakanas T, Andres A, Schiffer E. Perioperative Evolution of Sodium Levels in Cirrhotic Patients Undergoing Liver Transplantation: An Observational Cohort and Literature Review. Hepat Med 2021; 13:71-82. [PMID: 34393524 PMCID: PMC8357403 DOI: 10.2147/hmer.s320127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background & Aims Hyponatremia is an important predictor of early death among cirrhotic patients in the orthotopic liver transplantation (OLT) waiting list. Evidence exists that prioritizing OLT waiting list according to the MELD score combined with plasma sodium concentration might prevent pre transplantation death. However, the evolution of plasma sodium concentrations during the perioperative period of OLT is not well known. We aimed to describe the evolution of perioperative sodium concentration during OLT and its relation to perioperative neurohormonal responses. Methods Twenty-seven consecutive cirrhotic patients who underwent OLT were prospectively included in the study over a period of 27 months. We studied the evolution of plasma sodium levels, the hemodynamics, the neurohormonal response and other biological markers during the perioperative period of OLT. Results Among study's population, four patients had hyponatremia before OLT, all with Child cirrhosis. In patients with hyponatremia, plasmatic sodium reached normal levels during surgery, and sodium levels remained within normal ranges 1 day, 7 days, as well as 6 months after surgery for all patients. Creatinine clearance was decreased significantly during the perioperative period, while creatinine and cystatin C levels increased significantly. Neutrophil gelatinase-associated lipocalin (NGAL) and vasopressin levels did not change significantly in this period. Plasma renin activity, concentrations of norepinephrine and brain natriuretic peptide varied significantly during the perioperative period. Conclusion In our study, plasmatic sodium concentrations among hyponatremic cirrhotic patients undergoing OLT seem to reach normal levels after OLT and remain stable six months after surgery providing more evidence for the importance of sodium levels in prioritization of liver transplant candidates. Further investigation of rapid correction and stabilization of sodium levels after OLT, as observed in our study, would be of interest in order to fully understand the mechanisms involved in cirrhosis-related hyponatremia, its prognostic value and clinical implications.
Collapse
Affiliation(s)
- Ido Zamberg
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine University of Geneva, Geneva, Switzerland
| | - Julien Maillard
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Assouline
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Simon Tomala
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Gleicy Keli-Barcelos
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Florence Aldenkortt
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Mavrakanas
- Faculty of Medicine University of Geneva, Geneva, Switzerland.,Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Axel Andres
- Faculty of Medicine University of Geneva, Geneva, Switzerland.,Division of Transplantation, Department of Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Eduardo Schiffer
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine University of Geneva, Geneva, Switzerland
| |
Collapse
|
|
16
|
Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 431] [Impact Index Per Article: 107.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT
- VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain
- Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
| |
Collapse
|
|
17
|
McDonald MF, Barrett SC, Malik TH, Anand A, Keeling SS, Christmann CR, Goff CR, Galvan T, Kanwal F, Cholankeril G, Goss J, Rana A. Elevated serum sodium in recipients of liver transplantation has a substantial impact on outcomes. Transpl Int 2021; 34:1971-1983. [PMID: 34218471 DOI: 10.1111/tri.13968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 01/15/2023]
Abstract
Dysnatremias are a rare but significant event in liver transplantation. While recipient pre-transplant hypernatremia has been demonstrated to increase post-transplant mortality, the degree of hypernatremia and the impact of its resolution have been less well characterized. Here, we used multivariate Cox regression with a comprehensive list of donor and recipient factors in order to conduct a robust multivariate retrospective database study of 54,311 United Network for Organ Sharing (UNOS) liver transplant patients to analyze the effect of pre-transplant serum sodium on post-transplant mortality, post-transplant length of hospitalization, and post-transplant graft survival. Mortality and graft failure increased in a stepwise fashion with increasing pre-transplant hypernatremia: 145 -150 mEq/L (HR = 1.118 and HR = 1.113), 150-155 mEq/L (HR = 1.324 and HR = 1.306), and > 155 mEq/L (HR = 1.623 and HR = 1.661). Pre-transplant hypo- and hypernatremia also increased length of post-transplant hospitalization: < 125 mEq/L (HR = 1.098), 125-130 mEq/L (HR = 1.060), 145 -150 mEq/L (HR = 1.140), and 150-155 mEq/L (HR = 1.358). Resolution of hypernatremia showed no significant difference in mortality compared with normonatremia, while unresolved hypernatremia significantly increased mortality (HR = 1.254), including a durable long-term increased mortality risk for patients with creatinine < 2 mg/dL and MELD < 25. Pre-transplant hypernatremia serves as a morbid prognostic indicator for post-transplant morbidity and mortality.
Collapse
Affiliation(s)
- Malcolm F McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Spencer C Barrett
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Tahir H Malik
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Cameron R Goff
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Thao Galvan
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Margaret M and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Section of Gastroenterology and Hepatology, Margaret M and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
|
18
|
Goudsmit BFJ, Putter H, Tushuizen ME, de Boer J, Vogelaar S, Alwayn I, van Hoek B, Braat AE. Validation of the Model for End-stage Liver Disease sodium (MELD-Na) score in the Eurotransplant region. Am J Transplant 2021; 21:229-240. [PMID: 32529758 PMCID: PMC7818465 DOI: 10.1111/ajt.16142] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/12/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023]
Abstract
The MELD score is used in the Eurotransplant (ET) region to allocate liver grafts. Hyponatremia in cirrhotic patients is an important predictor of death but is not incorporated in MELD. This study investigated the performance of the MELD-Na score for the ET region. All adult patients with chronic liver disease on the ET liver transplantation waiting list (WL) allocated through lab MELD scores were included. The MELD-corrected effect of serum sodium (Na) concentration at listing on the 90-day WL mortality was calculated using Cox regression. The MELD-Na performance was assessed with c-indices, calibration per decile and Brier scores. The reclassification from MELD to MELD-Na score was calculated to estimate the impact of MELD-Na-based allocation in the ET region. For the 5223 included patients, the risk of 90-day WL death was 2.9 times higher for hyponatremic patients. The MELD-Na had a significantly higher c-index of 0.847 (SE 0.007) and more accurate 90-day mortality prediction compared to MELD (Brier score of 0.059 vs 0.061). It was estimated that using MELD-Na would reduce WL mortality by 4.9%. The MELD-Na score yielded improved prediction of 90-day WL mortality in the ET region and using MELD-Na for liver allocation will very likely reduce WL mortality.
Collapse
Affiliation(s)
- Ben F. J. Goudsmit
- Division of TransplantationDepartment of Surgery, Leiden University Medical CentreLeidenThe Netherlands,Eurotransplant International FoundationLeidenThe Netherlands,Division of TransplantationDepartment of Gastroenterology and Hepatology, Leiden University Medical CentreLeidenThe Netherlands
| | - Hein Putter
- Department of Biomedical Data SciencesLeidenThe Netherlands
| | - Maarten E. Tushuizen
- Division of TransplantationDepartment of Gastroenterology and Hepatology, Leiden University Medical CentreLeidenThe Netherlands
| | - Jan de Boer
- Eurotransplant International FoundationLeidenThe Netherlands
| | - Serge Vogelaar
- Eurotransplant International FoundationLeidenThe Netherlands
| | - I.P.J. Alwayn
- Division of TransplantationDepartment of Surgery, Leiden University Medical CentreLeidenThe Netherlands
| | - Bart van Hoek
- Division of TransplantationDepartment of Gastroenterology and Hepatology, Leiden University Medical CentreLeidenThe Netherlands
| | - Andries E. Braat
- Division of TransplantationDepartment of Surgery, Leiden University Medical CentreLeidenThe Netherlands
| |
Collapse
|
|
19
|
Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
| |
Collapse
|
|
20
|
Lenci I, Milana M, Grassi G, Signorello A, Aglitti A, Baiocchi L. Natremia and liver transplantation: The right amount of salt for a good recipe. World J Hepatol 2020; 12:919-930. [PMID: 33312419 PMCID: PMC7701977 DOI: 10.4254/wjh.v12.i11.919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/19/2020] [Accepted: 09/27/2020] [Indexed: 02/06/2023] Open
Abstract
An adequate balance between electrolytes and clear water is of paramount importance to maintaining physiologic homeostasis. Natremia imbalance and, in particular, hyponatremia is the most frequent electrolyte abnormality observed in hospitalized subjects, involving approximately one-fourth of them. Pathological changes occurring during liver cirrhosis predispose patients to an increased risk of sodium imbalance, and hypervolemic hyponatremia has been reported in nearly 50% of subjects with severe liver disease and ascites. Splanchnic vasodilatation, portal-systemic collaterals' opening and increased excretion of vasoactive modulators are all factors impairing clear water handling during liver cirrhosis. Of concern, sodium imbalance has been consistently reported to be associated with increased risk of complications and reduced survival in liver disease patients. In the last decades clinical interest in sodium levels has been also extended in the field of liver transplantation. Evidence that [Na+] in blood is an independent risk factor for in-list mortality led to the incorporation of sodium value in prognostic scores employed for transplant priority, such as model for end-stage liver disease-Na and UKELD. On the other hand, severe hyponatremic cirrhotic patients are frequently delisted by transplant centers due to the elevated risk of mortality after grafting. In this review, we describe in detail the relationship between sodium imbalance and liver cirrhosis, focusing on its impact on peritransplant phases. The possible therapeutic approaches, in order to improve transplant outcome, are also discussed.
Collapse
Affiliation(s)
- Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Martina Milana
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Giuseppe Grassi
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Alessandro Signorello
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Andrea Aglitti
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Leonardo Baiocchi
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy.
| |
Collapse
|
|
21
|
Hyponatremia Is Associated With Increased Mortality in Children on the Waiting List for Liver Transplantation. Transplant Direct 2020; 6:e604. [PMID: 33134484 PMCID: PMC7591120 DOI: 10.1097/txd.0000000000001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Our aim was to determine whether hyponatremia is associated with waiting list or posttransplantation mortality in children having liver transplantation (LT).
Collapse
|
|
22
|
Abstract
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.
Collapse
Affiliation(s)
- Joseph J. Alukal
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
| | - Savio John
- Division of Gastroenterology, Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Paul J. Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
|
23
|
Piano S, Tonon M, Angeli P. Ascites, Hyponatremia, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome. EVIDENCE‐BASED GASTROENTEROLOGY AND HEPATOLOGY 4E 2019:662-675. [DOI: 10.1002/9781119211419.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
24
|
Zhang QK, Wang ML. Value of Model for End-Stage Liver Disease-Serum Sodium Scores in Predicting Complication Severity Grades After Liver Transplantation for Acute-on-chronic Liver Failure. Transplant Proc 2019; 51:833-841. [DOI: 10.1016/j.transproceed.2019.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/04/2019] [Indexed: 02/06/2023]
|
|
25
|
Tasdogan BE, Akosman S, Gurakar M, Simsek C, Gurakar A. Update on Liver Transplantation: What is New Recently? Euroasian J Hepatogastroenterol 2019; 9:34-39. [PMID: 31988865 PMCID: PMC6969330 DOI: 10.5005/jp-journals-10018-1293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Liver transplantation (LT) is an evolving area of medicine for the treatment of certain types of malignancies and acute and chronic liver failures. Since the topic is evolving, new literature is increasingly available. In recent years, with the emerging potent antiviral therapies, hepatitis C virus-infected patients have successful patient and graft survival outcomes. Even human immunodeficiency virus (HIV) positive patients previously contraindicated for organ transplantation are transplanted with comparable outcomes. With increasing demand for LT, the shortage of the donor pool became the rate limiting factor in this hopeful treatment. To overcome waitlist mortality and expand the donor pool, scoring systems have been modified and organs from HIV and/or hepatitis C infected donors are now accepted, under certain circumstances. The new literature also questions the 6-month alcohol abstinence rule for the transplantation of alcoholic liver disease (ALD), in light of early transplantation results from severe alcoholic hepatitis (SAH) trials. How to cite this article: Tasdogan BE, Akosman S, et al. Update on Liver Transplantation: What is New Recently? Euroasian J Hepatogastroenterol 2019;9(1):34-39.
Collapse
Affiliation(s)
- Burcak E Tasdogan
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Sinan Akosman
- The Johns Hopkins University, Baltimore, Maryland, United States
| | - Merve Gurakar
- The Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Cem Simsek
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Ahmet Gurakar
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| |
Collapse
|
|
26
|
Intraoperative hyponatremia is an independent predictor of one-year mortality after liver transplantation. Sci Rep 2018; 8:18023. [PMID: 30575797 PMCID: PMC6303312 DOI: 10.1038/s41598-018-37006-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/25/2018] [Indexed: 01/15/2023] Open
Abstract
Preoperative hyponatremia is associated with an increased risk of mortality on the liver transplantation (LT) waiting list. We sought to investigate the impact of pre- and intraoperative serum sodium levels on the one-year mortality after LT. We identified 1,164 patients for whom preoperative and intraoperative serum sodium levels were available. Cox regression analysis with multivariable adjustment was performed for one-year mortality. A propensity score matching analysis was performed for preoperative and intraoperative serum sodium groups to compare one-year survival. The cutoff of sodium level with minimal p-value was 130 mEq/L for both preoperative and intraoperative sodium. Intraoperative hyponatremia was an independent predictor of one-year mortality in the multivariable Cox regression analysis, while preoperative hyponatremia was not. Kaplan-Meier curve showed that there was a significant difference in the one-year mortality between preoperative and intraoperative serum sodium groups. However, after propensity score matching, there was no difference in the one-year mortality among the preoperative sodium groups, while there was a significant difference among the intraoperative sodium groups. Intraoperative hyponatremia defined by mean sodium <130 mEq/L was independently associated with a significantly high one-year mortality. Mean intraoperative serum sodium levels may be a better prognostic predictor than preoperative serum sodium levels.
Collapse
|
|
27
|
Leise M, Cárdenas A. Hyponatremia in Cirrhosis: Implications for Liver Transplantation. Liver Transpl 2018; 24:1612-1621. [PMID: 30129266 DOI: 10.1002/lt.25327] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/18/2018] [Accepted: 08/08/2018] [Indexed: 12/14/2022]
Abstract
Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. Overcorrection of hyponatremia before LT or perioperatively can lead to the devastating neurologic condition known as osmotic demyelination syndrome, which is often irreversible and fatal. Therefore, the most important tenet of hyponatremia is to avoid correcting the serum sodium by ≥8 mEq/L in a 24-hour period. Treatment of hyponatremia is highly challenging. The vast majority of patients with cirrhosis have chronic hypervolemic hyponatremia. Fluid restriction increases serum sodium levels, but tolerance and compliance are significant barriers. Diuretic withdrawal is helpful but contributes to worsening fluid overload. There are limited data to support use of intravenous concentrated albumin solutions. The use of the arginine vasopressin antagonists ("vaptans") is contentious; however, they may have a limited role. Risk factors for intraoperative overcorrection of serum sodium include increased utilization of packed red blood cell and fresh frozen plasma transfusions, which are often unavoidable. Intraoperative management is evolving, and more data are needed in regard to the use of sodium-reduced continuous venovenous hemofiltration and the use of trishydroxymethylaminomethane (Tris) to avoid excess sodium rebound. A thorough discussion of the current treatment options before and during LT is given in this review.
Collapse
Affiliation(s)
- Michael Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Andrés Cárdenas
- GI/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi Sunyer, Ciber de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| |
Collapse
|
|
28
|
Niewińsk G, Raszeja-Wyszomirska J, Główczyńska R, Figiel W, Zając K, Kornasiewicz O, Zieniewicz K, Grąt M. Risk Factors of Prolonged ICU Stay in Liver Transplant Recipients in a Single-Center Experience. Transplant Proc 2018; 50:2014-2017. [PMID: 30177100 DOI: 10.1016/j.transproceed.2018.02.143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prolonged initial intensive care unit (ICU) stay after liver transplantation (LT) is associated with prolonged total hospitalization, increased hospital mortality, and impaired patient and graft survival. Recent data suggested that model for end-stage liver disease (MELD) score at the time of LT and the length of surgery were the two independent risk factors for an ICU stay longer than 3 days after LT. We further identified factors influencing prolonged ICU stay in single-center liver graft recipients. PATIENTS AND METHODS One hundred fifty consecutive LT recipients (M/F 94/56, median age 55 (range, 39-60), 36% with viral hepatitis, were prospectively enrolled into the study. Associations between clinical factors and prolonged ICU stay were evaluated using logistic regression models. Receiver operating characteristic curves were analyzed to determine the appropriate cutoffs for continuous variables. Threshold for significance was P ≤ .05. RESULTS Highly prolonged (≥8 days) and moderately prolonged (≥6 days) postoperative ICU stay was noted in 19 (12.7%) and 59 (39.3%) patients, respectively. Serum bilirubin (P = .001) and creatinine concentrations (P = .011), international normalized ratio (P = .004), and sodium-MELD (P < .001) were all significantly associated with postoperative intensive care unit stay over or equal to 75th percentile (6 days). Sodium-MELD was significantly associated with postoperative care unit stay greater or equal to the 90th percentile (8 days; P = .018). CONCLUSIONS Sodium-MELD might be a novel risk factor of prolonged ICU stay in this single-center experience.
Collapse
Affiliation(s)
- G Niewińsk
- II Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - J Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.
| | - R Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - W Figiel
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - K Zając
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - O Kornasiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - K Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
|
29
|
Utility of Tolvaptan in the Perioperative Management of Severe Hyponatremia During Liver Transplantation: A Case Report. Transplant Proc 2018; 49:2399-2401. [PMID: 29198689 DOI: 10.1016/j.transproceed.2017.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/23/2017] [Indexed: 12/27/2022]
Abstract
Severe hyponatremia can complicate the pretransplantation management of patients with decompensated cirrhosis while they await liver transplantation. Before the liver transplant, it is critical to correct severe hyponatremia to an appropriate level to reduce the risks of perioperative complications such as central pontine myelinolysis, cerebral edema, and seizures. Vasopressin receptor antagonists, and in particular tolvaptan, offer a therapeutic modality that can correct severe refractory hyponatremia in a timely and predictable manner before liver transplantation. In this case report, we describe a patient with decompensated cirrhosis and severe hyponatremia in whom administration of tolvaptan led to an optimal correction of preoperative severe hyponatremia and allowed for successful liver transplantation with no associated postoperative complications. In light of the increasing pretransplantation disease severity and higher risk of severe hyponatremia, the use of tolvaptan in the pretransplant period may gain increasing importance as a therapeutic intervention for maintaining peritransplant sodium homeostasis.
Collapse
|
|
30
|
Lenci I, Milana M, Angelico M, Baiocchi L. Short-Term, Low-Dose Use of Tolvaptan as a Bridge Therapy to Expedite Liver Transplant for Severe Hyponatremic, Cirrhotic Patients With High Model for End-Stage Liver Disease Scores. EXP CLIN TRANSPLANT 2017; 15:689-692. [PMID: 26581411 DOI: 10.6002/ect.2015.0209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
For patients on liver transplant waiting lists, hyponatremia is associated with increased mortality before transplant and complications during the early posttransplant period. Conventional therapies, such as fluid restriction or hypertonic saline infusion, are of limited value. We describe 2 patients with high Model for End-Stage Liver Disease scores (> 30) who were referred to our unit for expedited liver transplant. While on waiting lists, these patients developed severe hyponatremia (< 125 mEq/L) that was refractory to conventional therapies. Low-dose, short-term tolvaptan therapy (15 mg/d for 5 d) was then administered, as a bridge therapy to transplant, resulting in prompt restoration of serum sodium levels without any major clinical event. One patient died a few days later as no suitable grafts were available. The other received a liver transplant, and the outcome was uneventful. In conclusion, our report demonstrates that a short-term, low-dose tolvaptan-based strategy promptly resolves hyponatremia in patients who are on expedited waiting lists for liver transplant, allowing surgery with improved sodium levels and possibly limiting peritransplant complications.
Collapse
Affiliation(s)
- Ilaria Lenci
- From the Hepatology Unit, Department of Medicine, Policlinico Universitario Tor Vergata, Rome, Italy
| | | | | | | |
Collapse
|
|
31
|
Hsu YL, Hsieh CE, Lin KH, Chou CT, Lin PY, Wang SH, Chen YL. Central Pontine Myelinolysis After Living-Donor Liver Transplant: A Report of 2 Cases. EXP CLIN TRANSPLANT 2017; 17:564-567. [PMID: 29137593 DOI: 10.6002/ect.2017.0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Here, we present 2 patients who developed central pontine myelinolysis after living-donor liver transplant. Both patients had abnormal sodium level before living-donor liver transplant. Patient 1 presented with severe hyponatremia on admission. After administration of 3% saline, her sodium level during the first 24 hours was kept at 100 mEq/L and then increased to 116 mEq/L during the next 24 hours. The level increased 5.8 mEq/L during the 4- to 5-hour transplant procedure. Patient 2 was admitted to the hospital with an unprovoked seizure. The serum sodium concentration was 111 mEq/L, which was treated with 3% saline infusion. Serum sodium concentration escalated to 118 mEq/L over an 8-hour period. Intraoperatively, both patients received large amounts of replacement fluids (0.9% normal saline and albumin), blood transfusion, and sodium bicarbonate during the anhepatic phase, all of which carry high sodium load. Variations in sodium levels changed rapidly in patient 1 during transplant surgery. After they underwent liver transplant, patient 1 had clear mental status and patient 2 demonstrated worsened mental status. On approximately day 14 and day 4 after liver transplant, magnetic resonance imaging showed diffuse abnormalities of the pons, resulting in diagnosis of central pontine myelinolysis. Although both patients survived, 1 remains in a vegetative state and the other continues to present with mild balance and swallowing abnormalities. To reduce the chance of inadvertent overcorrection in patients with hyponatremia, it is therefore important that sodium concentrations should be monitored frequently and fluids and electrolytes titrated carefully.
Collapse
Affiliation(s)
- Ya-Lan Hsu
- From the Department of Nursing, Changhua Christian Hospital, Changhua, Taiwan
| | | | | | | | | | | | | |
Collapse
|
|
32
|
Rana A, Witte ED, Halazun KJ, Sood GK, Mindikoglu AL, Sussman NL, Vierling JM, Kueht ML, Galvan NTN, Cotton RT, O'Mahony CA, Goss JA. Liver transplant length of stay (LOS) index: A novel predictive score for hospital length of stay following liver transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13141] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Abbas Rana
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| | - Ellen D. Witte
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| | - Karim J. Halazun
- Department of Surgery; Division of Liver Transplantation and Hepatobiliary Surgery; New York-Presbyterian/Weill Cornell Medical Center; New York NY USA
| | - Gagan K. Sood
- Department of Medicine; Section of Gastroenterology and Hepatology; Baylor College of Medicine; Houston TX USA
| | - Ayse L. Mindikoglu
- Department of Medicine; Section of Gastroenterology and Hepatology; Baylor College of Medicine; Houston TX USA
| | - Norman L. Sussman
- Department of Medicine; Section of Gastroenterology and Hepatology; Baylor College of Medicine; Houston TX USA
| | - John M. Vierling
- Department of Medicine; Section of Gastroenterology and Hepatology; Baylor College of Medicine; Houston TX USA
| | - Michael L. Kueht
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| | - Nhu Thao N. Galvan
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| | - Ronald T. Cotton
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| | - Christine A. O'Mahony
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| | - John A. Goss
- Michael E. DeBakey Department of Surgery; Division of Abdominal Transplantation and Division of Hepatobiliary Surgery; Baylor College of Medicine; Houston TX USA
| |
Collapse
|
|
33
|
Nadim MK, DiNorcia J, Ji L, Groshen S, Levitsky J, Sung RS, Kim WR, Andreoni K, Mulligan D, Genyk YS. Inequity in organ allocation for patients awaiting liver transplantation: Rationale for uncapping the model for end-stage liver disease. J Hepatol 2017; 67:517-525. [PMID: 28483678 PMCID: PMC7735955 DOI: 10.1016/j.jhep.2017.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/23/2017] [Accepted: 04/17/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIM The goal of organ allocation is to distribute a scarce resource equitably to the sickest patients. In the United States, the Model for End-stage Liver Disease (MELD) is used to allocate livers for transplantation. Patients with greater MELD scores are at greater risk of death on the waitlist and are prioritized for liver transplant (LT). The MELD is capped at 40 however, and patients with calculated MELD scores >40 are not prioritized despite increased mortality. We aimed to evaluate waitlist and post-transplant survival stratified by MELD to determine outcomes in patients with MELD >40. METHODS Using United Network for Organ Sharing data, we identified patients listed for LT from February 2002 through to December 2012. Waitlist candidates with MELD ⩾40 were followed for 30days or until the earliest occurrence of death or transplant. RESULTS Of 65,776 waitlisted patients, 3.3% had MELD ⩾40 at registration, and an additional 7.3% had MELD scores increase to ⩾40 after waitlist registration. A total of 30,369 (46.2%) underwent LT, of which 2,615 (8.6%) had MELD ⩾40 at transplant. Compared to MELD 40, the hazard ratio of death within 30days of registration was 1.4 (95% CI 1.2-1.6) for patients with MELD 41-44, 2.6 (95% CI 2.1-3.1) for MELD 45-49, and 5.0 (95% CI 4.1-6.1) for MELD ⩾50. There was no difference in 1- and 3-year survival for patients transplanted with MELD >40 compared to MELD=40. A survival benefit associated with LT was seen as MELD increased above 40. CONCLUSIONS Patients with MELD >40 have significantly greater waitlist mortality but comparable post-transplant outcomes to patients with MELD=40 and, therefore, should be given priority for LT. Uncapping the MELD will allow more equitable organ distribution aligned with the principle of prioritizing patients most in need. Lay summary: In the United States (US), organs for liver transplantation are allocated by an objective scoring system called the Model for End-stage Liver Disease (MELD), which aims to prioritize the sickest patients for transplant. The greater the MELD score, the greater the mortality without liver transplant. The MELD score, however, is artificially capped at 40 and thus actually disadvantages the sickest patients with end-stage liver disease. Analysis of the data advocates uncapping the MELD score to appropriately prioritize the patients most in need of a liver transplant.
Collapse
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, CA, United States.
| | - Joseph DiNorcia
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA, United States
| | - Lingyun Ji
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, United States
| | - Susan Groshen
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, United States
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Randall S Sung
- Section of Transplant Surgery, University of Michigan, Ann Arbor, MI, United States
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, United States
| | - Kenneth Andreoni
- Division of Abdominal Transplantation Surgery, University of Florida, Gainesville, FL, United States
| | - David Mulligan
- Section of Transplantation and Immunology, Yale University School of Medicine, New Haven, CT, United States
| | - Yuri S Genyk
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
|
34
|
Shchekochikhin DY, Kozlovskaya NL, Kopylov FY, Syrkin AL, Shilov EM. Hyponatremia: A clinical approach. TERAPEVT ARKH 2017; 89:134-140. [DOI: 10.17116/terarkh2017898134-140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hyponatremia is the most common electrolyte metabolic abnormality in clinical practice. The unfavorable course of many diseases is associated with hyponatremia. Acute severe hyponatremia is life-threatening because cerebral edema may develop. Less obvious chronic hyponatremia increases the risk of balance problems, falls and fractures, especially in elderly patients. In any occasion, hyponatremia should not be now regarded only as a laboratory phenomenon in critically ill patients, but it necessitates a thorough clinical analysis of each individual case and appropriate therapy. The paper presents approaches to diagnosing and treating hyponatremia in various clinical situations.
Collapse
|
|
35
|
Jiménez JV, Carrillo-Pérez DL, Rosado-Canto R, García-Juárez I, Torre A, Kershenobich D, Carrillo-Maravilla E. Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 2017; 62:1855-1871. [PMID: 28501971 DOI: 10.1007/s10620-017-4597-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/26/2017] [Indexed: 12/17/2022]
Abstract
Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
Collapse
Affiliation(s)
- José Víctor Jiménez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Diego Luis Carrillo-Pérez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Rodrigo Rosado-Canto
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - David Kershenobich
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Eduardo Carrillo-Maravilla
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico.
| |
Collapse
|
|
36
|
Leise MD, Findlay JY. Hyponatremia in the perioperative period: When and how to correct. Clin Liver Dis (Hoboken) 2017; 9:111-114. [PMID: 30992972 PMCID: PMC6467151 DOI: 10.1002/cld.630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/22/2016] [Accepted: 01/28/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michael D. Leise
- William J. von Liebig Center for Transplantation and Clinical Regeneration,Division of Gastroenterology & Hepatology
| | | |
Collapse
|
|
37
|
Fortune B, Cardenas A. Ascites, refractory ascites and hyponatremia in cirrhosis. Gastroenterol Rep (Oxf) 2017; 5:104-112. [PMID: 28533908 PMCID: PMC5421465 DOI: 10.1093/gastro/gox010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/09/2017] [Indexed: 02/06/2023] Open
Abstract
Ascites is the most common complication related to cirrhosis and is associated with increased morbidity and mortality. Ascites is a consequence of the loss of compensatory mechanisms to maintain the overall effective arterial blood volume due to worsening splanchnic arterial vasodilation as a result of clinically significant portal hypertension. In order to maintain effective arterial blood volume, vasoconstrictor and antinatriuretic pathways are activated, which increase overall sodium and fluid retention. As a result of progressive splanchnic arterial vasodilation, intestinal capillary pressure increases and results in the formation of protein-poor fluid within the abdominal cavity due to increased capillary permeability from the hepatic sinusoidal hypertension. In some patients, the fluid can translocate across diaphragmatic fenestrations into the pleural space, leading to hepatic hydrothorax. In addition, infectious complications such as spontaneous bacterial peritonitis can occur. Eventually, as the liver disease progresses related to higher portal pressures, loss of a compensatory cardiac output and further splanchnic vasodilation, kidney function becomes compromised from worsening renal vasoconstriction as well as the development of impaired solute-free water excretion and severe sodium retention. These mechanisms then translate into significant clinical complications, such as refractory ascites, hepatorenal syndrome and hyponatremia, and all are linked to increased short-term mortality. Currently, liver transplantation is the only curative option for this spectrum of clinical manifestations but ongoing research has led to further insight on alternative approaches. This review will further explore the current understanding on the pathophysiology and management of ascites as well as expand on two advanced clinical consequences of advanced liver disease, refractory ascites and hyponatremia.
Collapse
Affiliation(s)
- Brett Fortune
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, NY, USA
| | - Andres Cardenas
- Institut de Malalties Digestives i Metabolique, Hospital Clinic, University of Barcelona, Barcelona, Spain
| |
Collapse
|
|
38
|
Sarici KB, Karakas S, Otan E, Ince V, Koc C, Koc S, Bayraktar H, Aydin C, Kayaalp C, Gungor S, Kablan Y, Yilmaz S. Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen? Transplant Proc 2017; 49:571-574. [PMID: 28340835 DOI: 10.1016/j.transproceed.2017.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation. METHODS In Inonu University's Liver Transplant Institute, 69 patients who made an emergency notice to the National Coordination Center for liver transplantation owing to FLF from January 2012 to December 2015 were included in the study. Patients were divided into 2 groups. Group 1 consisted of 52 patients who underwent liver transplantation and recovered normal brain function, and group 2 had 17 patients who underwent liver transplantation and did not recover normal brain function and had cerebral death. All patients were evaluated before surgery for clinical encephalopathy stage, light reflex, and convulsions. Groups were compared and assessed according to age (>40, 10-40 and <10 years), body mass index, etiologic factor, preoperative laboratory values, transplantation type, mortality, and encephalopathy level. Multivariate analysis was done for specific parameters. RESULTS Prothrombin time (PT), international normalized ratio (INR), and total bilirubin values were significantly different between the groups. There was no significant difference between the groups regarding ammonia and lactate levels. There was a statistically significant difference between the groups regarding sodium and potassium levels from serum electrolytes. However, the averages of both groups were within normal limits. pH and total bilirubin levels were meaningful for multivariate analysis. CONCLUSIONS HE reversibility, mortality, and morbidity are important in patients with HE who undergo liver transplantation. Therefore, West Haven clinical staging and serum INR, PT, and total bilirubin level may be helpful in predicting the reversibility of FLF patients with HE before liver transplantation. It was determined that West Haven encephalopathy grading is important in determining the reversibility of HE after transplantation in FLF; especially the probability of reversibility of stage 4 HE decreases significantly. High PT and INR levels, hyperbilirubinemia, and serum sodium and potassium concentrations were risk factors for the reversibility of HE in this study.
Collapse
Affiliation(s)
- K B Sarici
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey.
| | - S Karakas
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - E Otan
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - V Ince
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - C Koc
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - S Koc
- Department of Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - H Bayraktar
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - C Aydin
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - C Kayaalp
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - S Gungor
- Department of Pediatric Neurology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Y Kablan
- Department of Neurology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - S Yilmaz
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| |
Collapse
|
|
39
|
Ling Q, Dai H, Zhuang R, Shen T, Wang W, Xu X, Zheng S. Predicting short-term survival after liver transplantation on eight score systems: a national report from China Liver Transplant Registry. Sci Rep 2017; 7:42253. [PMID: 28198820 PMCID: PMC5304182 DOI: 10.1038/srep42253] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/08/2017] [Indexed: 12/16/2022] Open
Abstract
To compare the performance of eight score systems (MELD, uMELD, MELD-Na. iMELD, UKELD, MELD-AS, CTP, and mCTP) in predicting the post-transplant mortality, we analyzed the data of 6,014 adult cirrhotic patients who underwent liver transplantation between January 2003 and December 2010 from the China Liver Transplant Registry database. In hepatitis B virus (HBV) group, MELD, uMELD and MELD-AS showed good predictive accuracies at 3-month mortality after liver transplantation; by comparison with other five models, MELD presented the best ability in predicting 3-month, 6-month and 1-year mortality, showing a significantly better predictive ability than UKELD and iMELD. In hepatitis C virus and Alcohol groups, the predictive ability did not differ significantly between MELD and other models. Patient survivals in different MELD categories were of statistically significant difference. Among patients with MELD score >35, a new prognostic model based on serum creatinine, need for hemodialysis and moderate ascites could identify the sickest one. In conclusion, MELD is superior to other score systems in predicting short-term post-transplant survival in patients with HBV-related liver disease. Among patients with MELD score >35, a new prognostic model can identify the sickest patients who should be excluded from waiting list to prevent wasteful transplantation.
Collapse
Affiliation(s)
- Qi Ling
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haojiang Dai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Runzhou Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tian Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
|
40
|
Rana A, Kueht M, Desai M, Lam F, Miloh T, Moffett J, Galvan NTN, Cotton R, O'Mahony C, Goss J. No Child Left Behind: Liver Transplantation in Critically Ill Children. J Am Coll Surg 2017; 224:671-677. [PMID: 28167225 DOI: 10.1016/j.jamcollsurg.2016.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Advances in critical care prolong survival in children with liver failure, allowing more critically ill children to undergo orthotopic liver transplantation (OLT). In order to justify the use of a scarce donor resource and avoid futile transplants, we sought to determine survival in children who undergo OLT while receiving pre-OLT critical care. STUDY DESIGN We analyzed 13,723 pediatric OLTs using the United Network for Organ Sharing (UNOS) database from 1987 to 2015, including 6,746 recipients in the Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) era (2002 to 2015). There were 1,816 recipients (26.9%) admitted to the ICU at the time of transplantation. We also analyzed 354 pediatric OLT recipients at our center from 2002 to 2015, one of the largest institutional experiences. Sixty-five recipients (18.3%) were admitted to the ICU at the time of transplantation. Kaplan-Meier, volume threshold, and multivariable analyses were performed. RESULTS Patient survival improved steadily over the study period, (66% 1-year survival in 1987 vs 92% in 2015; p < 0.001). Our institutional experience of ICU recipients in the MELD/PELD era had acceptable outcomes (87% 1-year survival), even among our sickest recipients with vasoactive medications, mechanical ventilation, dialysis, and molecular adsorbent recirculating system requirements. Volume analysis revealed inferior outcomes (hazard ratio [HR] 1.68; 95% CI 1.11 to 2.51) in low-volume centers (<5 annual cases). Identifiable risk factors (previous transplantation, elevated serum sodium, hemodialysis, mechanical ventilation, body weight < 6 kg, and low center volume) increased risk of mortality. CONCLUSIONS This analysis demonstrates that the use of advanced critical care in children and infants with liver failure is justified because OLT can be performed on the sickest children and acceptable outcomes achieved. It is an appropriate use of a scarce donor allograft in a child who would otherwise succumb to a terminal liver disease.
Collapse
Affiliation(s)
- Abbas Rana
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.
| | - Michael Kueht
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX
| | - Moreshwar Desai
- Department of Pediatrics, Division of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong Lam
- Department of Pediatrics, Division of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Tamir Miloh
- Department of Pediatrics, Division of Hepatology/Gastroenterology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jennifer Moffett
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX
| | - N Thao N Galvan
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX
| | - Ronald Cotton
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX
| | - Christine O'Mahony
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX
| | - John Goss
- Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX
| |
Collapse
|
|
41
|
Pruinelli L, Monsen KA, Gross CR, Radosevich DM, Simon GJ, Westra BL. Predictors of Liver Transplant Patient Survival. Prog Transplant 2016; 27:98-106. [DOI: 10.1177/1526924816680099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient’s survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Data Source: Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014. Study Selection: Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation. Data Extraction: Predictors were extracted from 26 studies that met the inclusion criteria. Data Synthesis: Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions). Conclusions: The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.
Collapse
Affiliation(s)
| | - Karen A. Monsen
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia R. Gross
- School of Nursing and College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - David M. Radosevich
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - György J. Simon
- Department of Health Science Research, Mayo Clinic Rochester, Rochester, MN, USA
| | - Bonnie L. Westra
- School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
|
42
|
Murthy T. The journey of liver transplantation: Milestones covered and the road ahead. J Anaesthesiol Clin Pharmacol 2016; 32:283-5. [PMID: 27625472 PMCID: PMC5009830 DOI: 10.4103/0970-9185.188825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tvsp Murthy
- Department of Anaesthesiology and Critical Care, Command Hospital, AFMC, Pune, Maharashtra, India
| |
Collapse
|
|
43
|
Han SS, Han M, Park JY, An JN, Park S, Park SK, Han DJ, Na KY, Oh YK, Lim CS, Kim YS, Kim YH, Lee JP. Posttransplant Hyponatremia Predicts Graft Failure and Mortality in Kidney Transplantation Recipients: A Multicenter Cohort Study in Korea. PLoS One 2016; 11:e0156050. [PMID: 27214138 PMCID: PMC4877062 DOI: 10.1371/journal.pone.0156050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 05/09/2016] [Indexed: 11/18/2022] Open
Abstract
Although hyponatremia is related to poorer outcomes in several clinical settings, its significance remains unresolved in kidney transplantation. Data on 1,786 patients who received kidney transplantations between January 2000 and December 2011 were analyzed. The patients were divided into two groups according to the corrected sodium values for serum glucose 3 months after their transplantations (<135 mmol/L vs. ≥135 mmol/L). Subsequently, the hazard ratios (HRs) for biopsy-proven acute rejection, graft failure, and all-cause mortality were calculated after adjustments for several immunological and non-immunological covariates. 4.0% of patients had hyponatremia. Patients with hyponatremia had higher risks for graft failure and all-cause mortality than did the counterpart normonatremia group; the adjusted HRs for graft failure and mortality were 3.21 (1.47-6.99) and 3.03 (1.21-7.54), respectively. These relationships remained consistent irrespective of heart function. However, hyponatremia was not associated with the risk of acute rejection. The present study addressed the association between hyponatremia and graft and patient outcomes in kidney transplant recipients. Based on the study results, our recommendation is to monitor serum sodium levels after kidney transplantations.
Collapse
Affiliation(s)
- Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Miyeun Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Yoon Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Nam An
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seokwoo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Su-Kil Park
- Department of Internal Medicine, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea
| | - Duck-Jong Han
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.,Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
|
44
|
Sinha VK, Ko B. Hyponatremia in Cirrhosis--Pathogenesis, Treatment, and Prognostic Significance. Adv Chronic Kidney Dis 2015; 22:361-7. [PMID: 26311597 DOI: 10.1053/j.ackd.2015.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/06/2015] [Accepted: 02/12/2015] [Indexed: 01/14/2023]
Abstract
Cirrhosis is characterized by systemic and splanchnic vasodilation that leads to excessive nonosmotic secretion of vasopressin (antidiuretic hormone). Hyponatremia is a common electrolyte abnormality in advanced liver disease that results from the impaired ability of the kidney to excrete solute-free water that leads to "dilutional" hyponatremia-water retention disproportionate to the retention of sodium. Hyponatremia in liver diseases carries the prognostic burden, correlates with the severity of cirrhosis, and, in recent studies, has also been implicated in the pathogenesis of hepatic encephalopathy. The current treatment options are limited to conventional therapies like fluid restriction, and the outcomes are unsatisfactory. Although currently available vasopressin (V2 receptors) antagonists have been shown to increase serum sodium concentrations and improve ascites control, their role in the treatment of hyponatremia in liver disease patients remains questionable because of adverse effect profiles, high cost, and poor data on long-term mortality benefits. More information is needed to argue the benefits vs risks of short-term use of vaptans for correction of hyponatremia especially just hours-to-days before liver transplant.
Collapse
|
|
45
|
Yan L, Xie F, Lu J, Ni Q, Shi C, Tang C, Yang J. The treatment of vasopressin V2-receptor antagonists in cirrhosis patients with ascites: a meta-analysis of randomized controlled trials. BMC Gastroenterol 2015; 15:65. [PMID: 26054761 PMCID: PMC4460759 DOI: 10.1186/s12876-015-0297-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 05/29/2015] [Indexed: 12/15/2022] Open
Abstract
Background Ascites is the most common complication of cirrhosis. It may lead to the consequence of poor prognosis and the deterioration of quality of life. Asopressin V2 receptor antagonists is a kind of vaptans, and it has been proved to be effective in hyponatremia patients. We conducted a meta-analysis about treatment of vaptans in cirrhosis patients with ascites. Methods Following our selection criteria, we collected a total of 14 studies containing 16 randomized controlled trials (2620 patients) from a series of database about the treatment with vaptans for cirrhosis with ascites patients. The included studies compared the treatment effect of lixivaptan (VPA 985), or RMJ-351647, or satavaptan, or tolvaptan with placebo. Results The included vaptans (asopressin V2 receptor antagonists) showed significant effect of increasing the serum sodium concentration for cirrhosis patients (WMD = 2.11 mmol/L, p < 0.00001). Patients also could acquire significant improvement of ascites, as this kind of aquaretics can significantly reduce ascites patients’ weight (WMD = −1.53, p < 0.00001), abdominal girth (WMD = −2.04, p < 0.00001), and the ratio of worsening ascites (RR = 0.51, p = 0.001). Though the drug did not produce more total adverse events (RR = 1.04, p = 0.09) and the total serious events (RR = 1.04, p = 0.42), the emergence of excessive correction of serum sodium concentrations (>145 mmol/L) was more frequently noted in patients under the employment of vaptans (RR = 2.14, 95 % CI [1.45, 3.16], p = 0.0001). Whether with the administration of vaptans for short-term or long-term, no survival benefit was detected from the selected studies. Conclusions Asopressin V2 receptor antagonists could play an effective and safe role in symptomatic treatment for cirrhosis patients with ascites, especially for refractory ascites patients who presented insufficient response to conventional diuretics.
Collapse
Affiliation(s)
- Long Yan
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Feng Xie
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Jiongjiong Lu
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Qingqiang Ni
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Changying Shi
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Caixi Tang
- Hepatobiliary and pancreatic surgery center, Zhuzhou Central Hospital, Zhuzhou, 412007, China.
| | - Jiamei Yang
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| |
Collapse
|
|
46
|
Urso C, Brucculeri S, Caimi G. Employment of vasopressin receptor antagonists in management of hyponatraemia and volume overload in some clinical conditions. J Clin Pharm Ther 2015; 40:376-85. [PMID: 25924179 DOI: 10.1111/jcpt.12279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/07/2015] [Indexed: 12/21/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hyponatraemia, the most common electrolyte imbalance occurring in hospitalized subjects, is usually classified as hypovolaemic, euvolaemic or hypervolaemic. Hyponatraemia is a predictor of death among subjects with chronic heart failure and cirrhosis. The inappropriate secretion of the antidiuretic hormone (AVP) seems to be of pivotal importance in the decline of serum sodium concentration in these clinical conditions. The objective of this review was to summarize recent progress in management of hyponatraemia in SIADH, cirrhosis and heart failure. METHODS Literature searches were conducted on the topics of hyponatraemia and vasopressin receptor antagonists, using PubMed, pharmaceutical company websites and news reports. The information was evaluated for relevance and quality, critically assessed and summarized. RESULTS AND DISCUSSION The initial treatment of severe hyponatraemia is directed towards the prevention or management of neurological manifestations and consists of an intravenous infusion of hypertonic saline. Fluid restriction is indicated in oedematous states. Diuretics alone or in combination with other specific drugs remain the main strategy in the management of volume overload in heart failure. In resistant cases, ultrafiltration can lead to effective removal of isotonic fluid preventing new episodes of decompensation; however, aquapheresis is associated with increased costs and other limits. In several trials, the efficacy of vasopressin receptor antagonists in euvolaemic patients (inappropriate antidiuretic hormone secretion) or in hypervolaemic hyponatraemia (chronic heart failure, cirrhosis) has been evaluated. It was found that vaptans, which promote aquaresis, were superior to a placebo in raising and maintaining serum sodium concentrations in these subjects. WHAT IS NEW AND CONCLUSIONS Combined with conventional therapy, vasopressin receptor antagonists (AVP-R antagonists) are able to increase the excretion of electrolyte-free water and the sodium concentration. Further studies are needed to assess efficacious outcomes of aquaresis compared with aquapheresis and with conventional therapy.
Collapse
Affiliation(s)
- C Urso
- Dipartimento Biomedico di Medicina Interna e Specialistica, Universitá di Palermo, Palermo, Italy
| | - S Brucculeri
- Dipartimento Biomedico di Medicina Interna e Specialistica, Universitá di Palermo, Palermo, Italy
| | - G Caimi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Universitá di Palermo, Palermo, Italy
| |
Collapse
|
|
47
|
John S, Thuluvath PJ. Hyponatremia in cirrhosis: pathophysiology and management. World J Gastroenterol 2015; 21:3197-3205. [PMID: 25805925 PMCID: PMC4363748 DOI: 10.3748/wjg.v21.i11.3197] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/02/2014] [Accepted: 01/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. The development of ascites in patients with cirrhosis is multi-factorial. Portal hypertension and the associated systemic vasodilation lead to activation of the sodium-retaining neurohumoral mechanisms which include the renin-angiotensin-aldosterone system, sympathetic nervous system and antidiuretic hormone (ADH). The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume resulting in the development of ascites. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and ascites leads to impairment of the kidneys to eliminate solute- free water. This leads to additional compensatory mechanisms including non-osmotic secretion of ADH, also known as arginine vasopressin, further worsening excess water retention and thereby hyponatremia. Hyponatremia is associated with increased morbidity and mortality in patients with cirrhosis, and is an important prognostic marker both before and after liver transplant. The management of hyponatremia in this setting is a challenge as conventional therapy for hyponatremia including fluid restriction and loop diuretics are frequently inefficacious. In this review, we discuss the pathophysiology and various treatment modalities, including selective vasopressin receptor antagonists, for the management of hyponatremia in patients with cirrhosis.
Collapse
|
|
48
|
Piano S, Morando F, Angeli P. Hyponatremia and other electrolyte/ion disorders. CIRRHOSIS: A PRACTICAL GUIDE TO MANAGEMENT 2015:199-211. [DOI: 10.1002/9781118412640.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
49
|
Qi M, Luis V, Bilbao S, Omori K, Rawson J, McFadden B, Juan J, Nair I, Mullen Y, El-Shahawy M, Dafoe D, Kandeel F, Al-Abdullah IH. Sodium levels of human pancreatic donors are a critical factor for determination of islet efficacy and survival. Am J Physiol Endocrinol Metab 2015; 308:E362-9. [PMID: 25537495 DOI: 10.1152/ajpendo.00443.2014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Organs from hypernatremia (elevated Na+) donors when used for transplantation have had dismal outcomes. However, islet isolation from hypernatremic donors for both transplantation and research applications has not yet been investigated. A retrospective analysis of in vivo and in vitro islet function studies was performed on islets isolated from hypernatremic (serum sodium levels≥160 meq/l) and normal control (serum sodium levels≤155 meq/l) donors. Twelve isolations from 32 hypernatremic and 53 isolations from 222 normal donors were randomly transplanted into diabetic NOD Scid mice. Sodium levels upon pancreas procurement were significantly elevated in the hypernatremia group (163.5±0.6 meq/l) compared with the normal control group (145.9±0.4 meq/l) (P<0.001). The postculture islet recovery rate was significantly lower in the hypernatremia (59.1±3.8%) group compared with the normal (73.6±1.8%) group (P=0.005). The duration of hypernatremia was inversely correlated with the recovery rate (r2=0.370, P<0.001). Furthermore, the percentage of successful graft function when transplanted into diabetic NOD Scid mice was significantly lower in the hypernatremia (42%) group compared with the normal control (85%) group (P<0.001). The ability to predict islet graft function posttransplantation using donor sodium levels and duration of hypernatremia was significant (ROC analysis, P=0.022 and 0.042, respectively). In conclusion, duration of donor hypernatremia is associated with reduced islet recovery postculture. The efficacy of islets from hypernatremia donors diminished when transplanted into diabetic recipients.
Collapse
Affiliation(s)
- Meirigeng Qi
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Valiente Luis
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Shiela Bilbao
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Keiko Omori
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Jeffrey Rawson
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Brian McFadden
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Jemily Juan
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Indu Nair
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Yoko Mullen
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Mohamed El-Shahawy
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Donald Dafoe
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Fouad Kandeel
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Ismail H Al-Abdullah
- Department of Diabetes and Metabolic Diseases Research, Beckman Research Institute of the City of Hope, Duarte, California
| |
Collapse
|
|
50
|
Cárdenas A, Riggio O. Correction of hyponatraemia in cirrhosis: treating more than a number! J Hepatol 2015; 62:13-4. [PMID: 25281862 DOI: 10.1016/j.jhep.2014.09.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 09/25/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Andrés Cárdenas
- GI Unit, Institut Clinic de Malalties Digestives i Metaboliques, Hospital Clinic, and University of Barcelona, Spain.
| | - Oliviero Riggio
- GI and Liver Unit, Department of Clinical Medicine, "Sapienza" University of Rome, Italy
| |
Collapse
|