Hypochloremia is an underutilised prognostic marker in patients with advanced liver cirrhosis and liver failure

Table 1 Significance of serum sodium and chloride in patients with advanced liver cirrhosis

Parameter	Serum sodium (Na+)	Serum chloride (Cl-)
Primary role	Osmotic balance & water distribution	Renal salt sensing & acid-base homeostasis
Pathophysiology in cirrhosis/liver failure	Affected by RAAS, AVP, splanchnic vasodilation	Involvement in renal salt-sensing mechanisms, tubuloglomerular feedback & renin release
Common disturbance	Hyponatremia (< 130 mEq/L), often dilutional	Hypochloremia (< 98 mEq/L)
Prognostic role	Hyponatremia alone or in conjunction with MELD predicts short-term mortality	Independent predictor of mortality in advanced cirrhosis/liver failure patients
Clinical outcomes	Higher risk of death, hepatic decompensation, and need for liver transplant	Strong correlation with ICU mortality, hepatic decompensation, and long-term prognosis
Scoring models	Incorporated in MELD-Na for liver transplant candidates	MELD-Cl under evaluation; not yet standardised
Associations	Linked to renal function, ascites, bilirubin, and INR	Correlates with MELD, SOFA, Child-Pugh scores, lactate, and creatinine levels
ICU prognostication	Independent impact in severe cases declines	Superior prognostic value even after adjustments
Therapeutic benefit	Correcting hyponatremia may improves outcomes	It remains to be seen if treating hypochloremia improves outcomes

RAAS: Renin-angiotensin-aldosterone system; AVP: Arginine vasopressin; MELD: Model for End-Stage Liver Disease; INR: International normalized ratio; ICU: Intensive care unit; SOFA: Sequential Organ Failure Assessment.