Mx of Hyponatraemia in Liver Disease

Question 1

Mx of Hyponatraemia in Liver Cirrhosis

Answer 1

The management of hyponatraemia in liver cirrhosis is a difficult area and a consensus hasn’t been reached in all areas of management. However in patients with mild hyponatraemia (126-135 mmol/L) the recommendations are consistent. The British Society of Gastroenterology recommendations are as follows:

Sodium 126-135 mmol/L with normal creatinine - Continue normal diuretic regimen and observe, do not fluid restrict the patient.

Sodium 121-125 mmol/L with normal creatinine - International opinion is to continue diuretics, however, the British Society of Gastroenterology recommend a more cautious approach, and suggest either stopping diuretics or reducing the dose.

Sodium 121-125 mmol/L with raised creatinine (>150 mmol/L or >120 mmol/L and rising) - Stop diuretics and volume expand with human albumin solution 4.5%, gelofusine, or haemaccel

Sodium <121 mmol/L - Incredibly controversial, but the British society of gastroenterology suggest stopping diuretics and volume expanding with human albumin solution 4.5%, gelofusine, or haemaccel (which all contain sodium concentrations similar to that of normal saline).

They do, however, recognise that the level of evidence for this recommendation is 5 (or D) i.e. expert opinion, and further work needs to be done into the role of volume expansion and fluid restriction in cirrhosis.

Question 2

Mx of Hyponatraemia in Liver Disease - Example Question

Answer 2

You are working on the gastroenterology ward in your local district general hospital, doing a ward round, when you come to examine one of your well known NASH (non-alcoholic steatohepatitis) cirrhosis patients. He’s a 43-year-old man who had been admitted to the ward 3 days ago with a lower respiratory tract infection which has responded well to antibiotics. The patient appears clinically well from the end of the bed and has no complaints. He says that his ascites has been reasonably well managed over the past 4 years since diagnosis, needing only one ascitic drain during the admission that led to the diagnosis. On examination his chest appears to be clear today, his abdomen is soft and non-tender, and you can elicit a small amount of ascites on examination.

His blood results from this morning are as follows:

Hb 118 g/l
Platelets 102 * 109/l
WBC 4.5 * 109/l

Na+ 128 mmol/l
K+ 4.2 mmol/l
Urea 1.4 mmol/l
Creatinine 45 µmol/l

Bilirubin 20 µmol/l
ALP 134 u/l
ALT 24 u/l
Albumin 30 g/l

He tells you that his sodium has always given him a bit of trouble, and looking back at old results you noted that his usual sodium in clinic is consistently 133. His only medication is spironolactone 100mg twice daily

How should you manage this patient’s hyponatraemia?

Carry on spironolactone and fluid restrict to 1L/day
Stop spironolactone and fluid restrict to 1L/day
Reduce spironolactone to 50mg twice daily and monitor
> No change to medications - just monitor
Stop spironolactone and monitor

Sodium 126-135 mmol/L with normal creatinine - Continue normal diuretic regimen and observe, do not fluid restrict the patient.