Rapid Correction Rate of Hyponatremia as an Independent Risk Factor for Neurological Complication Following Liver Transplantation

Abstract

Hyponatremia is prevalent before liver transplantation and generally corrected immediately after transplantation. However, the clinical significance of correction rate of hyponatremia is not well investigated. The prognostic impact of pre-transplant serum sodium concentrations and post-transplant correction rate of hyponatremia were assessed. A total of 512 patients who received orthotopic liver transplants were enrolled. The correction rate of hyponatremia (delta sodium, ΔNa) was calculated based on the data collected during the first 48 hours following liver transplantation. Outcomes, including in-hospital mortality, delirium, neurological complications, acute kidney injury, and infections, were compared according to the serum sodium levels (sNa < 125, 125-135, and ≥ 135 mmol/L), and the risk factors for in-hospital mortality and neurological complications were analyzed using multivariate logistic regression methods. Patients with severe hyponatremia (sNa < 125 mmol/L) had higher rates of in-hospital mortality (9.6%, P = 0.010), delirium (54.8%, P = 0.003), neurological complications (24.7%, P = 0.003), and acute kidney injury (57.5%, P = 0.005). In multivariate analysis, serum sodium levels (OR = 0.975, P = 0.402) and delta sodium (OR = 1.097, P = 0.066) were not independent risk factors for in-hospital mortality. However, delta sodium (OR = 1.093, P = 0.003) and fast correction rate of hyponatremia (ΔNa ≥ 12 mmol/ L/24h, OR = 3.397, P = 0.023) were significantly associated with post-transplant neurological complications. Pre-transplantation hyponatremia was not independently associated with clinical outcomes. However, rapid correction of hyponatremia is an independent risk factor for the development of post-transplant neurological complications.

Hyponatremia Improvement Is Associated with a Reduced Risk of Mortality: Evidence from a Meta-Analysis

“…However, 49 of them were excluded because they did not included information about serum [Na + ] improvement (n = 37) or about mortality (n = 12) (see S2 file ). Four additional studies were excluded because they did not specifically address the association between mortality rate and serum [Na + ] improvement or normalization ( Table 2 ) [ 19 , 35 – 37 ]. Among the 15 selected studies, 7 studies evaluated the effect of hyponatremia improvement on overall mortality rate in subjects with heart failure, 2 in hospitalized series of subjects, one each including patients subjected to orthopic liver transplantation, admitted to an emergency room or to an intensive care unit, affected by lung cancer, myocardial infarction or pulmonary acute embolism ( Table 1 ).…”

Employment of vasopressin receptor antagonists in management of hyponatraemia and volume overload in some clinical conditions

“…Liver transplantation quickly restores hepatic function which, along with large volume of isotonic fluids given during surgery, may result in rapid correction of hyponatraemia with risk of ODS. Pre‐operative use of hypertonic saline may minimize this risk …”

“…Hypertonic sodium chloride has been used in the treatment of severe hyponatraemia in cirrhosis, but its efficacy is limited and is associated with increasing ascites and oedema; it is indicated only in cirrhotics who are very hyponatraemic and at only hours away from liver transplantation. The partial correction before transplantation is preferable to the rapid adjustment in the operating room to avoid ODS …”

Serum sodium shift in hyponatremic patients undergoing liver transplantation: a retrospective cohort study

“…14 Several studies have shown hyponatremia to be a poor prognostic indicator for cirrhotic patients receiving LTx. 9,[15][16][17][18] Yun et al 9 found that pre-operative hyponatremia is associated with an increased risk for post-operative ODS, along with prolonged stay in both ICU and hospital. On the other hand, few studies have focused on the rate of peri-operative SNa correction and its relationship with postoperative neurologic outcomes.…”

“…On the other hand, few studies have focused on the rate of peri-operative SNa correction and its relationship with postoperative neurologic outcomes. [18][19][20] Yu et al 19 demonstrated a 3.5% incidence of ODS post-LTx that was associated with an increased rate of SNa correction.…”