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World J Hepatol. Nov 27, 2020; 12(11): 919-930
Published online Nov 27, 2020. doi: 10.4254/wjh.v12.i11.919
Natremia and liver transplantation: The right amount of salt for a good recipe
Ilaria Lenci, Martina Milana, Giuseppe Grassi, Alessandro Signorello, Andrea Aglitti, Leonardo Baiocchi
Ilaria Lenci, Martina Milana, Giuseppe Grassi, Alessandro Signorello, Andrea Aglitti, Leonardo Baiocchi, Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
Author contributions: Lenci I collected, analyzed and interpreted the data, and drafted the manuscript and revised it critically; Milana M, Grassi G, Signorello A, and Aglitti A collected the data and revised the manuscript critically; Baiocchi L made the study proposal, conceived of the study, corrected the manuscript and revised it critically.
Conflict-of-interest statement: There are no conflicts of interest to disclose for any of the authors.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Leonardo Baiocchi, MD, PhD, Associate Professor, Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Viale Oxford 81, Rome 00133, Italy. baiocchi@uniroma2.it
Received: August 6, 2020
Peer-review started: August 6, 2020
First decision: September 17, 2020
Revised: September 19, 2020
Accepted: September 27, 2020
Article in press: September 27, 2020
Published online: November 27, 2020
Processing time: 109 Days and 16.6 Hours
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. 

Keywords: Sodium imbalance; Liver transplant; Cirrhosis; Vaptan; Transplant list; Hypervolemic hyponatremia

Core Tip: Sodium imbalance represents an important issue in cirrhotic patients. In the last decades, the impact of altered sodium levels in the peritransplant phases has also gained a relevant clinical interest. In this review, we examined: (1) The determinants of an impaired sodium balance in the course of severe liver diseases; (2) The consequences of sodium imbalance on liver transplant; and (3) The possible corrective measures for this condition.