hyponatremia in cirrhosis of liver indore pedicon 2014
DESCRIPTION
CIRRHOSIS OF LIVER,HYPONATREMIATRANSCRIPT
HYPONATREMIA IN HYPONATREMIA IN CIRRHOSIS OF LIVERCIRRHOSIS OF LIVER
Dr Rajesh KulkarniPune
DefinitionDefinitionSerum Sodium below 130mEq/L
(in patients with cirrhosis).
Why Important?Why Important?Increased risk of hepatic
encephalopathy.Increased risk of hepatorenal
syndromeIncreased mortality and poor
prognosisLiver transplant> Risk of CPM
Types of HyponatremiaTypes of Hyponatremia
HYPOVOLEMICHYPONATREMIA
HYPERVOLEMICHYPONATREMIA
CAUSESExcessive Diuretic use
Diarrhea
(Loss of fluid)
Marked impairment of renal solute-free water excretion, resulting in disproportionate renal retention of water with respect to sodium retention.
FEATURESLack of edema and ascites,
signs of dehydration present
Presence of ascites and edema
Management of hypovolemic Management of hypovolemic hyponatremia hyponatremia
Give Normal Saline
Stop Diuretics
Management of Management of hypervolemic hyponatremia hypervolemic hyponatremia (with ascites) (with ascites) Aim: Increase renal solute-free water
excretion
METHODS TO ACHIEVE METHODS TO ACHIEVE AIMAIMDietary Salt RestrictionFluid RestrictionDiuretics
(In adults V2 receptor antagonists like Satavaptan are being tried)
Dietary Salt RestrictionDietary Salt Restriction1 to 2mEq/kg/day for infants and
children
1 to 2 g/day (44 to 88 mEq of sodium/day) in adolescents.
Only 10 %of patients with ascites will respond to sodium restriction alone
Sodium Content of Indian Sodium Content of Indian FoodFoodItem Sodium(mEq)
Table Salt 1 gm 17
Aloo Sabji(1 bowl) 0.48
Paratha or Roti 0.22
Vegetable stuffed paratha 0.5 to 1
Cows milk(100 ml) 3.2
White Bread(1 slice) 6.7
Biscuit 6.1
Avoid Pickles, Papad,
Bakery products Burgers,Pizza Cheese Salted Peanuts
Taste kahan hai?
Look at other sources of Na e.g.IV antibiotics generally contain 2.1–3.6 mmol of sodium per gram
Fluid restrictionFluid restrictionEfficacy is limited
Difficult in children
Controversial even in adults
DiureticsDiureticsThe goal of diuresis is a negative
fluid balance of 10 cc/kg/day.
Single morning dose of spironolactone (0.3 to3 mg/kg) along with furosemide (0.5 to2 mg/kg) in the ratio of 5:2.
Dual therapy : Early mobilization of fluid with furosemide as spironolactone takes several days for a therapeutic response.
Dual diuretic therapy can be changed over to monotherapy with spironolactone alone while obtaining satisfactory diuretic response
Too Much of a good thingToo Much of a good thingOver diuresis is associated with
intravascular depletion , renal impairment, hepatic encephalopathy & hyponatremia
When to stop diuretics?When to stop diuretics?
Serum Na:121–125 mmol/l, serum creatinine elevated(>150 μmol/l or >120 μmol/l and rising)
Stop diuretics and give volume expansion (NS or Colloids: 5 %, 25 % albumin)
Take Home MessagesTake Home Messages
Hyponatremia is common in cirrhosis.
Important to distinguish hypovolemic vs hypervolemic hyponatremia.
Cornerstone of treatment is DiureticsSodium restriction has some roleWatch for complications of diuretic
use