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Rajakumar A, Paulin S, Sam AF, Jothimani D, Rammohan A, Rela M. Impact of Perioperative Serum Sodium Levels on Outcomes Following Living Donor Liver Transplantation. J Clin Exp Hepatol 2025; 15:102511. [PMID: 40093507 PMCID: PMC11908579 DOI: 10.1016/j.jceh.2025.102511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Accepted: 01/29/2025] [Indexed: 03/19/2025] Open
Abstract
Background & objectives Preoperative hyponatremia has been shown to be associated with poor outcomes post-liver transplantation. We analyzed the impact of preoperative hyponatremia and perioperative sodium (Na) changes on outcomes following adult living donor liver transplantation. Methods After obtaining clearance from Institutional ethical Committee, a retrospective review of electronic database and medical records of all adult patients who underwent LDLT between January 2019 and September 2022 was done and relevant perioperative data were collected. Results The study cohort of 520 recipients was divided into four groups based on preoperative serum Na levels in mmol/L; 12 patients (2.3%) in Group A (<125); 66 patients (12.6%) in Group B (125-129); 216 patients (41.5%) in Group C (130-135) and 226 patients (43.4%) in Group D (136-145). MELD score, preoperative AKI, SBP, intraoperative ascites volume, volume of packed blood cells (PRC), other blood products and 25% albumin were significantly associated with the degree of hyponatremia. No other outcomes including mortality was associated any grade of hyponatremia. The delta sodium on postoperative day 1 was largest in Group A. The level of Na rise post-transplant on POD1 had an inverse correlation with preoperative Na levels [ r (520) -0.6, P < 0.001]. High delta sodium was not associated with neurological complications in this cohort. Group A patients had higher incidence of postoperative AKI requiring dialysis followed by groups B, C and D. Eighty-six (16.5%) patients had large delta-Na of >10 mmol/L. On univariate analysis, low pretransplant Na (<130mEq/L), preoperative AKI, SBP, higher MELD and ascitic volumes, intraoperative transfusions of PRC, blood products and 25% albumin, early allograft dysfunction and need for dialysis, were associated with larger delta-Na. On multivariate analysis, preoperative Na levels ≤130 mmol/L, intraoperative ascites and PRC transfusion were found to be independent risk factors for a large delta-Na. Conclusion Hyponatremia, being a factor associated with liver disease, might not by itself contribute to poor survival when the deleterious effects of large delta changes can be avoided. The results from this study reinforces the fact that with a cautious perioperative approach, patients with hyponatremia can be transplanted safely in LDLT settings.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Susan Paulin
- Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Amal Francis Sam
- Department of Liver Intensive Care and Anaesthesia, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Dinesh Jothimani
- Department of Hepatology and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Ashwin Rammohan
- Department of HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mohamed Rela
- Department of HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
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Chen Y, Li H, Zhang M, Wu Z, Fang H, Wen P, Zhang J, Guo W. Effects of donors' and recipients' preoperative serum sodium on the prognosis of liver transplantation. Sci Rep 2024; 14:20304. [PMID: 39218910 PMCID: PMC11366754 DOI: 10.1038/s41598-024-71218-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
Dysnatremia is common in donors and recipients of liver transplantation (LT). However, the influence of dysnatremia on LT prognosis remains controversial. This study aimed to investigate effects of donors' and recipients' serum sodium on LT prognosis. We retrospectively reviewed 248 recipients who underwent orthotopic LT at our center between January 2016 and December 2018. Donors and recipients perioperative and 3-year postoperative clinical data were included. Delta serum sodium was defined as the donors' serum sodium minus the paired recipients' serum sodium. Donors with serum sodium > 145 mmol/L had significantly higher preoperative blood urea nitrogen (BUN) (P < 0.01) and creatinine (Cr) (P < 0.01) than others. Preoperative total bilirubin (TBIL) (P < 0.01), direct bilirubin (DBIL) (P < 0.01), BUN (P < 0.01), Cr (P < 0.01) were significantly higher in the hyponatremia group of recipients than the other groups, but both of donors' and recipients' serum sodium had no effect on the LT prognosis. In the delta serum sodium < 0 mmol/L group, TBIL (P < 0.01) and DBIL (P < 0.01) were significantly higher in postoperative 1 week than the other groups, but delta serum sodium had no effect on the postoperative survival rates. Dysnatremia in donors and recipients of LT have no effect on postoperative survival rates, hepatic and renal function, but recipients with higher serum sodium than donors have significantly higher TBIL and DBIL at 1 week postoperatively.
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Affiliation(s)
- Yabin Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jian She Road, Zhengzhou, 450052, Henan, China
| | - Hao Li
- National Organ Transplantation (Liver &Kidney Transplantation) Physician Training Centre Zhengzhou, Henan, 450052, China
| | - Menggang Zhang
- National Regional Medical Treatment Centre of Henan Organ Transplantation, Zhengzhou, 450052, Henan, China
| | - Zeyu Wu
- Henan Organ Transplantation Centre, Zhengzhou, 450052, Henan, China
| | - Haoran Fang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jian She Road, Zhengzhou, 450052, Henan, China
| | - Peihao Wen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jian She Road, Zhengzhou, 450052, Henan, China
| | - Jiakai Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jian She Road, Zhengzhou, 450052, Henan, China
| | - Wenzhi Guo
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jian She Road, Zhengzhou, 450052, Henan, China.
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Yau AA, Buchkremer F. Hyponatremia in the Context of Liver Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:139-146. [PMID: 38649218 DOI: 10.1053/j.akdh.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/22/2023] [Accepted: 12/15/2023] [Indexed: 04/25/2024]
Abstract
Hyponatremia is common in patients with liver disease and is associated with increased mortality, morbidity, and a reduced quality of life. In liver transplantation, the inclusion of hyponatremia in organ allocation scores has reduced waitlist mortality. Portal hypertension and the resulting lowering of the effective arterial blood volume are important pathogenetic factors, but in most patients with liver disease, hyponatremia is multifactorial. Treatment requires a multifaceted approach that tries to reduce electrolyte-free water intake, restore urinary dilution, and increase nonelectrolyte solute excretion. Albumin therapy for hyponatremia is a peculiarity of advanced liver disease. Its use appears to be increasing, while the vaptans are currently only given in selected cases. Osmotic demyelination is a special concern in patients with liver disease. Serial checks of serum sodium concentrations and urine volume monitoring are mandatory.
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Affiliation(s)
- Amy A Yau
- Division of Nephrology, The Ohio State University, Columbus, OH
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Ng PY, Cheung RYT, Ip A, Chan WM, Sin WC, Yap DYH. A retrospective cohort study on the clinical outcomes of patients admitted to intensive care units with dysnatremia. Sci Rep 2023; 13:21236. [PMID: 38040748 PMCID: PMC10692105 DOI: 10.1038/s41598-023-48399-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/26/2023] [Indexed: 12/03/2023] Open
Abstract
With evolving patient characteristics and patterns of ICU utilization, the impact of dysnatremias on patient outcomes and healthcare costs in the present era have not been well studied. Patients ≥ 18 years admitted to the ICUs in public hospitals in Hong Kong between January 2010 and June 2022 and had at least one serum sodium measurement obtained within 24 h prior to or following ICU admission were stratified into normonatremic (135-145 mmol/L), hyponatremic (< 135 mmol/L) and hypernatremic (> 145 mmol/L) groups. A total of 162,026 patients were included-9098 (5.6%), 40,533 (25.0%) and 112,395 (69.4%) patients were hypernatremic, hyponatremic and normonatremic at the time of ICU admission, respectively. The odds of patients with hypernatremia and hyponatremia dying in the ICU were 27% and 14% higher (aOR 1.27, 95% CI 1.19-1.36 and aOR 1.14, 95% CI 1.08-1.19, respectively; P < 0.001 for both), and 52% and 21% higher for dying in the hospital (aOR 1.52, 95% CI 1.43-1.62 and aOR 1.21, 95% CI 1.17-1.26, respectively; P < 0.001 for both] compared with those with normonatremia. Patients with dysnatremia also had longer ICU length of stay (LOS), hospital LOS, and higher healthcare costs than the normonatremic group. Dysnatremias at ICU admission were associated with increased ICU and in-hospital mortality and overall healthcare burden.
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Affiliation(s)
- Pauline Yeung Ng
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong SAR, China
| | - Regina Yui Ting Cheung
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - April Ip
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai Ming Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong SAR, China
| | - Wai Ching Sin
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong SAR, China
| | - Desmond Yat-Hin Yap
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Room 301, 3/F New Clinical Building, 102 Pokfulam Road, Hong Kong SAR, China.
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5
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Liu Y, Hu H, Li Z, Yang Y, Chen F, Li W, Zhang L, Huang G. Association between preoperative serum sodium and postoperative 30-day mortality in adult patients with tumor craniotomy. BMC Neurol 2023; 23:355. [PMID: 37794369 PMCID: PMC10548693 DOI: 10.1186/s12883-023-03412-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Limited data exist regarding preoperative serum sodium (Na) and 30-day mortality in adult patients with tumor craniotomy. Therefore, this study investigates their relationship. METHODS A secondary retrospective analysis was performed using data from the ACS NSQIP database (2012-2015). The principal exposure was preoperative Na. The outcome measure was 30-day postoperative mortality. Binary logistic regression modeling was conducted to explore the link between them, and a generalized additive model and smooth curve fitting were applied to evaluate the potential association and its explicit curve shape. We also conducted sensitivity analyses and subgroup analyses. RESULTS A total of 17,844 patients (47.59% male) were included in our analysis. The mean preoperative Na was 138.63 ± 3.23 mmol/L. The 30-day mortality was 2.54% (455/17,844). After adjusting for covariates, we found that preoperative Na was negative associated with 30-day mortality. (OR = 0.967, 95% CI:0.941, 0.994). For patients with Na ≤ 140, each increase Na was related to a 7.1% decreased 30-day mortality (OR = 0.929, 95% CI:0.898, 0.961); for cases with Na > 140, each increased Na unit was related to a 8.8% increase 30-day mortality (OR = 1.088, 95% CI:1.019, 1.162). The sensitivity analysis and subgroup analysis indicated that the results were robust. CONCLUSIONS This study shows a positive and nonlinear association between preoperative Na and postoperative 30-day mortality in adult patients with tumor craniotomy. Appropriate preoperative Na management and maintenance of serum Na near the inflection point (140) may reduce 30-day mortality.
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Affiliation(s)
- Yufei Liu
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, No. 3002 Sungang west Road, Futian District, Shenzhen, Guangdong Province, 518035, China
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China
| | - Haofei Hu
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China
- Nephrological Department, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, 518035, China
| | - Zongyang Li
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, No. 3002 Sungang west Road, Futian District, Shenzhen, Guangdong Province, 518035, China
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China
| | - Yuandi Yang
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, No. 3002 Sungang west Road, Futian District, Shenzhen, Guangdong Province, 518035, China
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China
| | - Fanfan Chen
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, No. 3002 Sungang west Road, Futian District, Shenzhen, Guangdong Province, 518035, China
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China
| | - Weiping Li
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, No. 3002 Sungang west Road, Futian District, Shenzhen, Guangdong Province, 518035, China
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China
| | - Liwei Zhang
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Guodong Huang
- Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, No. 3002 Sungang west Road, Futian District, Shenzhen, Guangdong Province, 518035, China.
- Shenzhen University Health Science Center, Shenzhen city, Guangdong Province, 518000, China.
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Khalid MB, Nagorna A, Rippel N, Ezaz G, Schiano TD, Crismale JF. Early neurologic complications after liver transplant are associated with reduced long-term survival and increased rates of rejection. Liver Transpl 2023; 29:1079-1088. [PMID: 37147847 DOI: 10.1097/lvt.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023]
Abstract
Neurologic complications (NCs) are common following liver transplantation (LT) and have been associated with impaired short-term survival. The impact of NC on long-term survival is less defined. We aimed to characterize these outcomes and assess for risk factors for post-LT NC. We performed a single-center, retrospective review of 521 patients with LT from 2016 to 2020. Baseline clinical and laboratory factors, intraoperative events, and outcomes were compared between patients with and without NC. The 5-year overall and rejection-free survival was estimated using the Kaplan-Meier analysis. Multivariable logistic regression assessed for an independent relationship between risk factors and the development of NC. Among 521 LT recipients, 24% experienced post-LT NC. Overall and rejection-free survival at 5 years was, respectively, 69% and 75% among those with NC versus 87% and 88% among those without NC (log-rank < 0.001). Among those who survived the first 3 months after LT, overall survival but not rejection-free survival was reduced among patients with NC. Risk factors for developing NC included peri-LT serum sodium (ΔSNa) ≥ 6 (29.4% vs. 20.5%, p = 0.04), grade 3 or 4 HE pre-LT, SNa < 125 pre-LT, and more intraoperative transfusions. In a multivariable logistic regression model controlling for described variables, SNa < 125 (or 0.21, 95% CI, 0.06-0.74) at LT and pre-LT HE grade 3 or 4 (or 0.45, 95% CI, 0.26-0.76) was independently associated with NC. Long-term survival was reduced among patients who developed NC in the immediate post-transplant period, even when censoring those who died in the first 3 months. Post-LT NC was associated with perioperative ΔSNa ≥ 6. Optimization of SNa pre-LT > 125 and limiting perioperative ΔSNa <6 mEq/L might have a beneficial impact in decreasing NC post-LT, which may improve long-term post-LT survival.
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Affiliation(s)
- Mian B Khalid
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Agnieszka Nagorna
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Noa Rippel
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Ghideon Ezaz
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Thomas D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - James F Crismale
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Ryu JY, Baek SH, Kim S. Evidence-based hyponatremia management in liver disease. Clin Mol Hepatol 2023; 29:924-944. [PMID: 37280091 PMCID: PMC10577348 DOI: 10.3350/cmh.2023.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 06/08/2023] Open
Abstract
Hyponatremia is primarily a water balance disorder associated with high morbidity and mortality. The pathophysiological mechanisms behind hyponatremia are multifactorial, and diagnosing and treating this disorder remains challenging. In this review, the classification, pathogenesis, and step-by-step management approaches for hyponatremia in patients with liver disease are described based on recent evidence. We summarize the five sequential steps of the traditional diagnostic approach: 1) confirm true hypotonic hyponatremia, 2) assess the severity of hyponatremia symptoms, 3) measure urine osmolality, 4) classify hyponatremia based on the urine sodium concentration and extracellular fluid status, and 5) rule out any coexisting endocrine disorder and renal failure. Distinct treatment strategies for hyponatremia in liver disease should be applied according to the symptoms, duration, and etiology of disease. Symptomatic hyponatremia requires immediate correction with 3% saline. Asymptomatic chronic hyponatremia in liver disease is prevalent and treatment plans should be individualized based on diagnosis. Treatment options for correcting hyponatremia in advanced liver disease may include water restriction; hypokalemia correction; and administration of vasopressin antagonists, albumin, and 3% saline. Safety concerns for patients with liver disease include a higher risk of osmotic demyelination syndrome.
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Affiliation(s)
- Ji Young Ryu
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul University Bundang Hospital, Seongnam, Korea
- Center for Artificial Intelligence in Healthcare, Seoul University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Ganni S, Handing G, Anand A, Barrett S, Galvan NTN, O’Mahony C, Goss JA, Cotton RT, Rana A. Selecting DCD Recipients Using Predictive Indices. Transplant Direct 2023; 9:e1467. [PMID: 37009165 PMCID: PMC10065835 DOI: 10.1097/txd.0000000000001467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 04/04/2023] Open
Abstract
Donation after circulatory death (DCD) allografts might represent one of the largest untapped sources of liver allografts. Our aim was to identify independent recipient risk factors that predict mortality in DCD allograft recipients to preselect optimal candidates for successful transplantation. Furthermore, we compared the application of our newly constructed DCD Recipient Selector Index (RSI) score to previously developed models to determine superiority in predicting recipient survival. Methods Using the Organ Procurement and Transplantation Network database, we performed univariate and multivariate retrospective analyses on 4228 DCD liver allograft recipients. Results We identified 8 significant factors and incorporated them into the weighted RSI to predict 3-mo survival following DCD liver transplantation with a C-statistic of 0.6971. The most significant recipient risk factors were recipient serum sodium levels >150 mEq/L at transplant, recipient albumin <2.0 g/dL at transplant, and a history of portal vein thrombosis. Because Model for End-Stage Liver Disease (MELD) score components were included as individual predictors, the DCD RSI predicts survival independently of MELD. Upon comparison with 3 previous recipient risk scores-Balance of Risk, Renal Risk Index, Patient-Survival Outcomes Following Liver Transplantation-the DCD RSI was determined to be superior at selecting optimal candidates pre-DCD transplantation, yielding a C-statistic of 0.6971. Conclusions After verifying the performance of predictive indices for selection of DCD recipients, the DCD RSI is best used to preselect patients for optimized outcomes after DCD transplantation. This can increase utilization of DCD donors by improving outcomes.
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Affiliation(s)
- Saif Ganni
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Greta Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Spencer Barrett
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Christine O’Mahony
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - John A. Goss
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Ronald T. Cotton
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Abbas Rana
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
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9
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Teo CB, Gan MY, Tay RYK, Loh WJ, Loh NHW. Association of preoperative hyponatremia with surgical outcomes: a systematic review and meta-analysis of 32 observational studies. J Clin Endocrinol Metab 2022; 108:1254-1271. [PMID: 36472931 PMCID: PMC10099166 DOI: 10.1210/clinem/dgac685] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative hyponatremia is prevalent in patients undergoing surgical procedures, but it is uncertain if hyponatremia will lead to increased risk of surgical mortality and morbidity. METHODS A systematic search of Medline (PubMed), Embase and Cochrane Library from inception till 2 July 2021 was performed. Full length articles that reported on the association between surgical outcomes among adults ≥18 years with documented preoperative hyponatremia were included. FINDINGS We identified 32 observational studies comprising 1,301,346 participants. All studies had low risk of bias. When adjusted for covariates, patients with hyponatremia had significantly higher odds of developing major complications (defined as a composite measure of 9 major complications) compared to patients with normal sodium concentrations (aOR = 1.37, 95%CI = 1.23-1.53, I2 = 78%. N = 10). Additionally, patients with preoperative hyponatremia also significantly higher hazards of early mortality (<90 days) compared to patients with normonatremia (aHR = 1.27, 95%CI = 1.13-1.43, I2 = 97%. N = 10) after adjustment for covariates. Preoperative hyponatremia also had significant associations with respiratory, renal and septic complications. In terms of prognostic performance, preoperative hyponatremia performed adequately in predicting major complications in surgical patients (AUC = 0.70, LR- 0.90) with a specificity of 88% and a sensitivity of 25%. INTERPRETATION Our meta-analysis suggests that preoperative hyponatremia is associated with poorer early mortality and major morbidity outcomes in surgical patients. Hyponatremia is also a specific prognosticator for major complications in surgical patients, reiterating its potential use as a clinical indicator of poor outcomes.
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Affiliation(s)
- Chong Boon Teo
- Ministry of Health Holdings, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Ne-Hooi Will Loh
- Department of Anaesthesia, National University Hospital, Singapore
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10
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Abstract
Hyponatremia is the most common electrolyte disorder encountered in clinical practice, and it is a common complication of cirrhosis reflecting an increase in nonosmotic secretion of arginine vasopressin as a result of of the circulatory dysfunction that is characteristic of advanced liver disease. Hyponatremia in cirrhosis has been associated with poor clinical outcomes including increased risk of morbidity and mortality, poor quality of life, and heightened health care utilization. Despite this, the treatment of hyponatremia in cirrhosis remains challenging as conventional therapies such as fluid restriction are frequently ineffective. In this review, we discuss the epidemiology, clinical outcomes, pathogenesis, etiology, evaluation, and management of hyponatremia in cirrhosis.
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Affiliation(s)
- Helbert Rondon-Berrios
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Q. Velez
- Ochsner Clinical School/The University of Queensland, Brisbane, Queensland, Australia AND Department of Nephrology, Ochsner Health, New Orleans, Louisiana, USA
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11
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Verbeek TA, Saner FH, Bezinover D. Hyponatremia and Liver Transplantation: A Narrative Review. J Cardiothorac Vasc Anesth 2022; 36:1458-1466. [PMID: 34144870 DOI: 10.1053/j.jvca.2021.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 11/11/2022]
Abstract
Hyponatremia is a common electrolyte disorder in patients with end-stage liver disease (ESLD) and is associated with increased mortality on the liver transplantation (LT) waiting list. The impact of hyponatremia on outcomes after LT is unclear. Ninety-day and one-year mortality may be increased, but the data are conflicting. Hyponatremic patients have an increased rate of complications and longer hospital stays after transplant. Although rare, osmotic demyelination syndrome (ODS) is a feared complication after LT in the hyponatremic patient. The condition may occur when the serum sodium (sNa) concentration increases excessively during or after LT. This increase in sNa concentration correlates with the degree of preoperative hyponatremia, the amount of intraoperative blood loss, and the volume of intravenous fluid administration. The risk of developing ODS after LT can be mitigated by avoiding large perioperative increases in sNa concentration . This can be achieved through measures such as carefully increasing the sNa pretransplant, and by limiting the intravenous intra- and postoperative amounts of sodium infused. SNa concentrations should be monitored regularly throughout the entire perioperative period.
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Affiliation(s)
- Thomas A Verbeek
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA.
| | - Fuat H Saner
- Department of General, Visceral, and Transplantation Surgery, Essen University Medical Center, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA
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12
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Praharaj DL, Anand AC. Clinical Implications, Evaluation, and Management of Hyponatremia in Cirrhosis. J Clin Exp Hepatol 2022; 12:575-594. [PMID: 35535075 PMCID: PMC9077240 DOI: 10.1016/j.jceh.2021.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is the most common electrolyte abnormality in patients with decompensated cirrhosis on Liver Transplantation (LT) waiting list. Most of these patients have dilutional or hypervolemic hyponatremia secondary to splanchnic vasodilatation. Excessive secretion of the antidiuretic hormone also plays an important role. Hypervolemic hyponatremia is commonly associated with refractory ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy. Although uncommon, the use of diuretics and laxatives can cause hypovolemic hyponatremia that is characterized by the striking absence of ascites or pedal edema. Clinical features are often nonspecific and depend on the acuity of onset rather than the absolute value of serum sodium. Symptoms may be subtle, including nausea, lethargy, weakness, or anorexia. However, rarely patients may present with confusion, seizures, psychosis, or coma. Treatment includes discontinuation of diuretics, beta-blockers, and albumin infusion. Hypertonic saline (3%) infusion may be used in patients with very low serum sodium (<110 mmol/L) or when patients present with seizures or coma. Short-term use of Vasopressin (V2) receptor antagonists may also be used to normalize sodium levels prior to LT. However, all these measures may be futile, and LT remains the definite treatment in these patients to improve survival. In this review, we describe the classification, pathogenesis of hyponatremia, and its clinical implications in patients with cirrhosis. Approach to these patients along with management will also be discussed briefly.
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Key Words
- ACE, angiotensin-converting enzyme
- ACLF, acute-on-chronic liver failure
- ACTH, adrenocorticotropic hormone
- ADH
- ADH, antidiuretic hormone
- AKI, acute kidney injury
- AVP, arginine vasopressin
- CLIF, chronic liver failure
- CNS, central nervous system
- CTP, Child-Turcotte-Pugh
- CVVHD, continuous venovenous hemofiltration
- DAMP, damage-associated molecular patterns
- EABV, effective arterial blood volume
- FENa, fractional excretion of sodium
- HE, hepatic encephalopathy
- HRS, hepatorenal syndrome
- LT, liver transplantation
- LVP, large volume paracentesis
- MAP, mean arterial pressure
- MELD, model of end-stage liver disease
- NO, nitric oxide
- NSBB, nonselective beta-blockers
- PAMP, pathogen-associated molecular patterns
- PICD, paracentesis-induced circulatory dysfunction
- PPCD, post-paracentesis circulatory dysfunction
- PRA, plasma renin activity
- RA, refractory ascites
- RAAS, renin-angiotensin-aldosterone-system
- RAI, relative adrenal insufficiency
- RBF, renal blood flow
- SBP, spontaneous bacterial peritonitis
- SIADH, syndrome of inappropriate ADH secretion
- SMT, standard medical treatment
- SNS, sympathetic nervous system
- TBW, total body water
- TIPS, transjugular intrahepatic portosystemic shunt
- advanced cirrhosis
- albumin
- hyponatremia
- liver transplantation
- sNa, serum sodium
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Affiliation(s)
- Dibya L. Praharaj
- Address for correspondence. Dibya L Praharaj, Assistant Professor, Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Science, Bhubaneswar, India
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13
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Berchtold L, Filzer A, Achermann R, Devetzis V, Dahdal S, Bonani M, Schnyder A, Golshayan D, Amico P, Huynh-Do U, de Seigneux S, Arampatzis S, on behalf of Swiss Transplant Cohort Study Collaborators. Impact of Hyponatremia after Renal Transplantation on Decline of Renal Function, Graft Loss and Patient Survival: A Prospective Cohort Study. Nutrients 2021; 13:nu13092995. [PMID: 34578871 PMCID: PMC8468476 DOI: 10.3390/nu13092995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/19/2021] [Accepted: 08/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Hyponatremia is one of the most common electrolyte disorders observed in hospitalized and ambulatory patients. Hyponatremia is associated with increased falls, fractures, prolonged hospitalisation and mortality. The clinical importance of hyponatremia in the renal transplant field is not well established, so the aim of this study was to determine the relationships between hyponatremia and mortality as main outcome and renal function decline and graft loss as secondary outcome among a prospective cohort of renal transplant recipients. Methods: This prospective cohort study included 1315 patients between 1 May 2008 and 31 December 2014. Hyponatremia was defined as sodium concentration below 136 mmol/L at 6 months after transplantation. The main endpoint was mortality. A secondary composite endpoint was also defined as: rapid decline in renal function (≥5 mL/min/1.73 m2 drop of the eGFR/year), graft loss or mortality. Results: Mean sodium was 140 ± 3.08 mmol/L. 97 patients displayed hyponatremia with a mean of 132.9 ± 3.05 mmol/L. Hyponatremia at 6 months after transplantation was associated neither with mortality (HR: 1.02; p = 0.97, 95% CI: 0.47–2.19), nor with the composite outcome defined as rapid decline in renal function, graft loss or mortality (logrank test p = 0.9). Conclusions: Hyponatremia 6 months after transplantation is not associated with mortality in kidney allograft patients.
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Affiliation(s)
- Lena Berchtold
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, 1205 Geneva, Switzerland; (L.B.); (S.d.S.)
| | - Anja Filzer
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Rita Achermann
- Department of Transplant Immunology and Nephrology, University Hospital Basel, 4031 Basel, Switzerland; (R.A.); (P.A.)
| | - Vasileios Devetzis
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Suzan Dahdal
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Marco Bonani
- Division of Nephrology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Aurelia Schnyder
- Clinic for Nephrology and Transplant Medicine, Hospital of St. Gallen, 9007 St. Gallen, Switzerland;
| | - Dela Golshayan
- Centre for Organ Transplantation (CTO), 1011 Lausanne, Switzerland;
| | - Patrizia Amico
- Department of Transplant Immunology and Nephrology, University Hospital Basel, 4031 Basel, Switzerland; (R.A.); (P.A.)
| | - Uyen Huynh-Do
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
| | - Sophie de Seigneux
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, 1205 Geneva, Switzerland; (L.B.); (S.d.S.)
| | - Spyridon Arampatzis
- University Clinic for Nephrology and Hypertension, Inselspital, Bern University Hospital of Bern, 3010 Bern, Switzerland; (A.F.); (V.D.); (S.D.); (U.H.-D.)
- Correspondence: ; Tel.: +41-31-632-3111
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14
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Zamberg I, Maillard J, Assouline B, Tomala S, Keli-Barcelos G, Aldenkortt F, Mavrakanas T, Andres A, Schiffer E. Perioperative Evolution of Sodium Levels in Cirrhotic Patients Undergoing Liver Transplantation: An Observational Cohort and Literature Review. Hepat Med 2021; 13:71-82. [PMID: 34393524 PMCID: PMC8357403 DOI: 10.2147/hmer.s320127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background & Aims Hyponatremia is an important predictor of early death among cirrhotic patients in the orthotopic liver transplantation (OLT) waiting list. Evidence exists that prioritizing OLT waiting list according to the MELD score combined with plasma sodium concentration might prevent pre transplantation death. However, the evolution of plasma sodium concentrations during the perioperative period of OLT is not well known. We aimed to describe the evolution of perioperative sodium concentration during OLT and its relation to perioperative neurohormonal responses. Methods Twenty-seven consecutive cirrhotic patients who underwent OLT were prospectively included in the study over a period of 27 months. We studied the evolution of plasma sodium levels, the hemodynamics, the neurohormonal response and other biological markers during the perioperative period of OLT. Results Among study's population, four patients had hyponatremia before OLT, all with Child cirrhosis. In patients with hyponatremia, plasmatic sodium reached normal levels during surgery, and sodium levels remained within normal ranges 1 day, 7 days, as well as 6 months after surgery for all patients. Creatinine clearance was decreased significantly during the perioperative period, while creatinine and cystatin C levels increased significantly. Neutrophil gelatinase-associated lipocalin (NGAL) and vasopressin levels did not change significantly in this period. Plasma renin activity, concentrations of norepinephrine and brain natriuretic peptide varied significantly during the perioperative period. Conclusion In our study, plasmatic sodium concentrations among hyponatremic cirrhotic patients undergoing OLT seem to reach normal levels after OLT and remain stable six months after surgery providing more evidence for the importance of sodium levels in prioritization of liver transplant candidates. Further investigation of rapid correction and stabilization of sodium levels after OLT, as observed in our study, would be of interest in order to fully understand the mechanisms involved in cirrhosis-related hyponatremia, its prognostic value and clinical implications.
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Affiliation(s)
- Ido Zamberg
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine University of Geneva, Geneva, Switzerland
| | - Julien Maillard
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Assouline
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Simon Tomala
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Gleicy Keli-Barcelos
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Florence Aldenkortt
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Mavrakanas
- Faculty of Medicine University of Geneva, Geneva, Switzerland.,Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Axel Andres
- Faculty of Medicine University of Geneva, Geneva, Switzerland.,Division of Transplantation, Department of Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Eduardo Schiffer
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine University of Geneva, Geneva, Switzerland
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15
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 438] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT
- VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain
- Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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16
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McDonald MF, Barrett SC, Malik TH, Anand A, Keeling SS, Christmann CR, Goff CR, Galvan T, Kanwal F, Cholankeril G, Goss J, Rana A. Elevated serum sodium in recipients of liver transplantation has a substantial impact on outcomes. Transpl Int 2021; 34:1971-1983. [PMID: 34218471 DOI: 10.1111/tri.13968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 01/15/2023]
Abstract
Dysnatremias are a rare but significant event in liver transplantation. While recipient pre-transplant hypernatremia has been demonstrated to increase post-transplant mortality, the degree of hypernatremia and the impact of its resolution have been less well characterized. Here, we used multivariate Cox regression with a comprehensive list of donor and recipient factors in order to conduct a robust multivariate retrospective database study of 54,311 United Network for Organ Sharing (UNOS) liver transplant patients to analyze the effect of pre-transplant serum sodium on post-transplant mortality, post-transplant length of hospitalization, and post-transplant graft survival. Mortality and graft failure increased in a stepwise fashion with increasing pre-transplant hypernatremia: 145 -150 mEq/L (HR = 1.118 and HR = 1.113), 150-155 mEq/L (HR = 1.324 and HR = 1.306), and > 155 mEq/L (HR = 1.623 and HR = 1.661). Pre-transplant hypo- and hypernatremia also increased length of post-transplant hospitalization: < 125 mEq/L (HR = 1.098), 125-130 mEq/L (HR = 1.060), 145 -150 mEq/L (HR = 1.140), and 150-155 mEq/L (HR = 1.358). Resolution of hypernatremia showed no significant difference in mortality compared with normonatremia, while unresolved hypernatremia significantly increased mortality (HR = 1.254), including a durable long-term increased mortality risk for patients with creatinine < 2 mg/dL and MELD < 25. Pre-transplant hypernatremia serves as a morbid prognostic indicator for post-transplant morbidity and mortality.
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Affiliation(s)
- Malcolm F McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Spencer C Barrett
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Tahir H Malik
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Cameron R Goff
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Thao Galvan
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Margaret M and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Section of Gastroenterology and Hepatology, Margaret M and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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17
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Fonseca BSD, Souza VSD, Batista TOF, Silva GM, Spigolon DN, Derenzo N, Barbieri A. Strategies for hemodynamic maintenance of potential brain-dead donor: integrative review. EINSTEIN-SAO PAULO 2021; 19:eRW5630. [PMID: 34190847 PMCID: PMC8225261 DOI: 10.31744/einstein_journal/2021rw5630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 10/26/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To learn about the scientific production on strategies adopted for hemodynamic maintenance of brain-dead patients. METHODS Integrative review with articles published between 2007 and 2019, in Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), PubMed® and ScienceDirect. The descriptors " Hemodinâmica AND Morte Encefálica " and "Hemodynamics AND Brain Death" were used. Exclusion criteria were non-human research and gray literature. RESULTS A total of 21 articles were listed. As strategies, the use of drugs - noradrenaline (n=8), vasopressin (n=7), dobutamine (n=6), hydrocortisone (n=4) and methylprednisolone (n=4); invasive (n=10) and noninvasive (n=13) cardiac monitoring; control of ventilatory parameters (n=12); and correction of fluid and electrolyte disturbances (n=17) were highlighted. CONCLUSION The main strategies found in this integrative review were regulation of blood pressure and temperature, use of catecholamines and corticosteroids, in addition to the need for an early diagnosis of brain death. However, the lack of clearer protocols on the subject is notorious, making management with the potential donor difficult.
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Affiliation(s)
| | | | | | | | | | - Neide Derenzo
- Universidade Estadual do Paraná, Paranavaí, PR, Brazil
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18
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Thalji L, Thalji NM, Heimbach JK, Ibrahim SH, Kamath PS, Hanson A, Schulte PJ, Haile DT, Kor DJ. Renal Function Parameters and Serum Sodium Enhance Prediction of Wait-List Outcomes in Pediatric Liver Transplantation. Hepatology 2021; 73:1117-1131. [PMID: 32485002 DOI: 10.1002/hep.31397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 05/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Reliance on exception points to prioritize children for liver transplantation (LT) stems from concerns that the Pediatric End-Stage Liver Disease (PELD) score underestimates mortality. Renal dysfunction and serum sodium disturbances are negative prognosticators in adult LT candidates and various pediatric populations, but are not accounted for in PELD. We retrospectively evaluated the effect of these parameters in predicting 90-day wait-list death/deterioration among pediatric patients (<12 years) listed for isolated LT in the United States between February 2002 and June 2018. APPROACH AND RESULTS Among 4,765 patients, 2,303 (49.3%) were transplanted, and 231 (4.8%) died or deteriorated beyond transplantability within 90 days of listing. Estimated glomerular filtration rate (eGFR) (hazard ratio [HR] 1.09 per 5-unit decrease, 95% confidence interval [CI] 1.06-1.10) and dialysis (HR 7.24, 95% CI 3.57-14.66) were univariate predictors of 90-day death/deterioration (P < 0.001). The long-term benefit of LT persisted in patients with renal dysfunction, with LT as a time-dependent covariate conferring a 2.4-fold and 17-fold improvement in late survival among those with mild and moderate-to-severe dysfunction, respectively. Adjusting for PELD, sodium was a significant nonlinear predictor of outcome, with 90-day death/deterioration risk increased at both extremes of sodium (HR 1.20 per 1-unit decrease below 137 mmol/L, 95% CI 1.16-1.23; HR per 1-unit increase above 137 mmol/L 1.13, 95% CI 1.10-1.17, P < 0.001). A multivariable model incorporating PELD, eGFR, dialysis, and sodium demonstrated improved performance and superior calibration in predicting wait-list outcomes relative to the PELD score. CONCLUSIONS Listing eGFR, dialysis, and serum sodium are potent, independent predictors of 90-day death/deterioration in pediatric LT candidates, capturing risk not accounted for by PELD. Incorporation of these variables into organ allocation systems may highlight patient subsets with previously underappreciated risk, augment ability of PELD to prioritize patients for transplantation, and ultimately mitigate reliance on nonstandard exceptions.
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Affiliation(s)
- Leanne Thalji
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
| | | | | | - Samar H Ibrahim
- Department of PediatricsDivision of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Patrick S Kamath
- Department of MedicineDivision of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Andrew Hanson
- Division of Biomedical StatisticsMayo ClinicRochesterMN
| | | | - Dawit T Haile
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
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19
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Goudsmit BFJ, Putter H, Tushuizen ME, de Boer J, Vogelaar S, Alwayn I, van Hoek B, Braat AE. Validation of the Model for End-stage Liver Disease sodium (MELD-Na) score in the Eurotransplant region. Am J Transplant 2021; 21:229-240. [PMID: 32529758 PMCID: PMC7818465 DOI: 10.1111/ajt.16142] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/12/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023]
Abstract
The MELD score is used in the Eurotransplant (ET) region to allocate liver grafts. Hyponatremia in cirrhotic patients is an important predictor of death but is not incorporated in MELD. This study investigated the performance of the MELD-Na score for the ET region. All adult patients with chronic liver disease on the ET liver transplantation waiting list (WL) allocated through lab MELD scores were included. The MELD-corrected effect of serum sodium (Na) concentration at listing on the 90-day WL mortality was calculated using Cox regression. The MELD-Na performance was assessed with c-indices, calibration per decile and Brier scores. The reclassification from MELD to MELD-Na score was calculated to estimate the impact of MELD-Na-based allocation in the ET region. For the 5223 included patients, the risk of 90-day WL death was 2.9 times higher for hyponatremic patients. The MELD-Na had a significantly higher c-index of 0.847 (SE 0.007) and more accurate 90-day mortality prediction compared to MELD (Brier score of 0.059 vs 0.061). It was estimated that using MELD-Na would reduce WL mortality by 4.9%. The MELD-Na score yielded improved prediction of 90-day WL mortality in the ET region and using MELD-Na for liver allocation will very likely reduce WL mortality.
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Affiliation(s)
- Ben F. J. Goudsmit
- Division of TransplantationDepartment of Surgery, Leiden University Medical CentreLeidenThe Netherlands,Eurotransplant International FoundationLeidenThe Netherlands,Division of TransplantationDepartment of Gastroenterology and Hepatology, Leiden University Medical CentreLeidenThe Netherlands
| | - Hein Putter
- Department of Biomedical Data SciencesLeidenThe Netherlands
| | - Maarten E. Tushuizen
- Division of TransplantationDepartment of Gastroenterology and Hepatology, Leiden University Medical CentreLeidenThe Netherlands
| | - Jan de Boer
- Eurotransplant International FoundationLeidenThe Netherlands
| | - Serge Vogelaar
- Eurotransplant International FoundationLeidenThe Netherlands
| | - I.P.J. Alwayn
- Division of TransplantationDepartment of Surgery, Leiden University Medical CentreLeidenThe Netherlands
| | - Bart van Hoek
- Division of TransplantationDepartment of Gastroenterology and Hepatology, Leiden University Medical CentreLeidenThe Netherlands
| | - Andries E. Braat
- Division of TransplantationDepartment of Surgery, Leiden University Medical CentreLeidenThe Netherlands
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20
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Endpoints and design of clinical trials in patients with decompensated cirrhosis: Position paper of the LiverHope Consortium. J Hepatol 2021; 74:200-219. [PMID: 32896580 DOI: 10.1016/j.jhep.2020.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/09/2020] [Accepted: 08/02/2020] [Indexed: 12/15/2022]
Abstract
Management of decompensated cirrhosis is currently geared towards the treatment of complications once they occur. To date there is no established disease-modifying therapy aimed at halting progression of the disease and preventing the development of complications in patients with decompensated cirrhosis. The design of clinical trials to investigate new therapies for patients with decompensated cirrhosis is complex. The population of patients with decompensated cirrhosis is heterogeneous (i.e., different etiologies, comorbidities and disease severity), leading to the inclusion of diverse populations in clinical trials. In addition, primary endpoints selected for trials that include patients with decompensated cirrhosis are not homogeneous and at times may not be appropriate. This leads to difficulties in comparing results obtained from different trials. Against this background, the LiverHope Consortium organized a meeting of experts, the goal of which was to develop recommendations for the design of clinical trials and to define appropriate endpoints, both for trials aimed at modifying the natural history and preventing progression of decompensated cirrhosis, as well as for trials aimed at managing the individual complications of cirrhosis.
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Lenci I, Milana M, Grassi G, Signorello A, Aglitti A, Baiocchi L. Natremia and liver transplantation: The right amount of salt for a good recipe. World J Hepatol 2020; 12:919-930. [PMID: 33312419 PMCID: PMC7701977 DOI: 10.4254/wjh.v12.i11.919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/19/2020] [Accepted: 09/27/2020] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Martina Milana
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Giuseppe Grassi
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Alessandro Signorello
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Andrea Aglitti
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy
| | - Leonardo Baiocchi
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome 00133, Italy.
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Abstract
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.
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Affiliation(s)
- Joseph J. Alukal
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
| | - Savio John
- Division of Gastroenterology, Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Paul J. Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Stine JG, Stukenborg GJ, Wang J, Adkins A, Niccum B, Zimmet A, Argo CK. Liver transplant candidates have impaired quality of life across health domains as assessed by computerized testing. Ann Hepatol 2020; 19:62-68. [PMID: 31558420 PMCID: PMC7252261 DOI: 10.1016/j.aohep.2019.06.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/28/2019] [Accepted: 06/21/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver transplantation candidates are among the most comorbid patients awaiting lifesaving intervention. Health related quality of life (HRQOL) measured by instruments that incorporate dynamic computerized adaptive testing, could improve their assessment. We aimed to determine the feasibility of administration of the Patient-Reported Outcomes Measurement Information System (PROMIS-CAT) in liver transplant candidates. MATERIALS AND METHODS Liver transplantation candidates were prospectively enrolled following a review of their available medical history. Subjects were given a tablet computer (iPad) to access the pre-loaded PROMIS CAT. RESULTS 109 candidates with mean age 55.6±8.6 years were enrolled in this pilot study. Mean MELD-Na score was 16.3±6.3; 92.6% had decompensated liver disease. Leading etiologies of cirrhosis included hepatitis C (34.8%), nonalcoholic steatohepatitis (25.7%) and alcohol (21.1%). Subjects with MELD-Na score>20 had the most significant impairment in HRQOL (anxiety/fear+5.9±2.7, p=0.0289, depression+5.1±2.5, p=0.0428, fatigue+4.3±2.6, p=0.0973) and physical impairment (-7.8±2.5, p=0.0022). Stage of cirrhosis and decompensated liver disease were predictive of impaired HRQOL but Child-Pugh Turcotte score was not. Hepatic encephalopathy was the strongest independent predictor of impaired HRQOL, with significant impairment across all domains of health. CONCLUSIONS Liver transplant candidates have significantly impaired HRQOL across multiple domains of health as measured by PROMIS-CAT. HRQOL impairment parallels disease severity. Future study is needed to determine how best HRQOL could be systematically included in liver transplantation listing policy, especially in those candidates with hepatic encephalopathy.
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Affiliation(s)
- Jonathan G. Stine
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Virginia, Charlottesville, VA, USA,Corresponding author at: Assistant Professor of Medicine and Public Health Sciences, Liver Center Research Director, The Pennsylvania State University-Milton S. Hershey Medical Center, Division of Gastroenterology and Hepatology, 200 Campus Drive, Suite 4200, UPC II, Mail Code HU33, Hershey, PA 17033, USA. (J.G. Stine)
| | - George J. Stukenborg
- Department of Public Health Science, University of Virginia, Charlottesville, VA, USA
| | - Jennifer Wang
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Alden Adkins
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Blake Niccum
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Zimmet
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Curtis K. Argo
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Virginia, Charlottesville, VA, USA
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Park M, Son HJ, Kim GS. Osmotic Demyelination Syndrome Following Hyponatremia-Oriented Management in Liver Transplant: A Single Center 20-Year Experience. EXP CLIN TRANSPLANT 2019; 17:540-545. [DOI: 10.6002/ect.2018.0216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tasdogan BE, Akosman S, Gurakar M, Simsek C, Gurakar A. Update on Liver Transplantation: What is New Recently? Euroasian J Hepatogastroenterol 2019; 9:34-39. [PMID: 31988865 PMCID: PMC6969330 DOI: 10.5005/jp-journals-10018-1293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Liver transplantation (LT) is an evolving area of medicine for the treatment of certain types of malignancies and acute and chronic liver failures. Since the topic is evolving, new literature is increasingly available. In recent years, with the emerging potent antiviral therapies, hepatitis C virus-infected patients have successful patient and graft survival outcomes. Even human immunodeficiency virus (HIV) positive patients previously contraindicated for organ transplantation are transplanted with comparable outcomes. With increasing demand for LT, the shortage of the donor pool became the rate limiting factor in this hopeful treatment. To overcome waitlist mortality and expand the donor pool, scoring systems have been modified and organs from HIV and/or hepatitis C infected donors are now accepted, under certain circumstances. The new literature also questions the 6-month alcohol abstinence rule for the transplantation of alcoholic liver disease (ALD), in light of early transplantation results from severe alcoholic hepatitis (SAH) trials. How to cite this article: Tasdogan BE, Akosman S, et al. Update on Liver Transplantation: What is New Recently? Euroasian J Hepatogastroenterol 2019;9(1):34-39.
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Affiliation(s)
- Burcak E Tasdogan
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Sinan Akosman
- The Johns Hopkins University, Baltimore, Maryland, United States
| | - Merve Gurakar
- The Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Cem Simsek
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Ahmet Gurakar
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
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Intraoperative hyponatremia is an independent predictor of one-year mortality after liver transplantation. Sci Rep 2018; 8:18023. [PMID: 30575797 PMCID: PMC6303312 DOI: 10.1038/s41598-018-37006-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/25/2018] [Indexed: 01/15/2023] Open
Abstract
Preoperative hyponatremia is associated with an increased risk of mortality on the liver transplantation (LT) waiting list. We sought to investigate the impact of pre- and intraoperative serum sodium levels on the one-year mortality after LT. We identified 1,164 patients for whom preoperative and intraoperative serum sodium levels were available. Cox regression analysis with multivariable adjustment was performed for one-year mortality. A propensity score matching analysis was performed for preoperative and intraoperative serum sodium groups to compare one-year survival. The cutoff of sodium level with minimal p-value was 130 mEq/L for both preoperative and intraoperative sodium. Intraoperative hyponatremia was an independent predictor of one-year mortality in the multivariable Cox regression analysis, while preoperative hyponatremia was not. Kaplan-Meier curve showed that there was a significant difference in the one-year mortality between preoperative and intraoperative serum sodium groups. However, after propensity score matching, there was no difference in the one-year mortality among the preoperative sodium groups, while there was a significant difference among the intraoperative sodium groups. Intraoperative hyponatremia defined by mean sodium <130 mEq/L was independently associated with a significantly high one-year mortality. Mean intraoperative serum sodium levels may be a better prognostic predictor than preoperative serum sodium levels.
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27
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Leise M, Cárdenas A. Hyponatremia in Cirrhosis: Implications for Liver Transplantation. Liver Transpl 2018; 24:1612-1621. [PMID: 30129266 DOI: 10.1002/lt.25327] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/18/2018] [Accepted: 08/08/2018] [Indexed: 12/14/2022]
Abstract
Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. Overcorrection of hyponatremia before LT or perioperatively can lead to the devastating neurologic condition known as osmotic demyelination syndrome, which is often irreversible and fatal. Therefore, the most important tenet of hyponatremia is to avoid correcting the serum sodium by ≥8 mEq/L in a 24-hour period. Treatment of hyponatremia is highly challenging. The vast majority of patients with cirrhosis have chronic hypervolemic hyponatremia. Fluid restriction increases serum sodium levels, but tolerance and compliance are significant barriers. Diuretic withdrawal is helpful but contributes to worsening fluid overload. There are limited data to support use of intravenous concentrated albumin solutions. The use of the arginine vasopressin antagonists ("vaptans") is contentious; however, they may have a limited role. Risk factors for intraoperative overcorrection of serum sodium include increased utilization of packed red blood cell and fresh frozen plasma transfusions, which are often unavoidable. Intraoperative management is evolving, and more data are needed in regard to the use of sodium-reduced continuous venovenous hemofiltration and the use of trishydroxymethylaminomethane (Tris) to avoid excess sodium rebound. A thorough discussion of the current treatment options before and during LT is given in this review.
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Affiliation(s)
- Michael Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Andrés Cárdenas
- GI/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi Sunyer, Ciber de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
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Abstract
OBJECTIVES To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child. DESIGN Literature review and expert commentary. MEASUREMENT AND MAIN RESULTS Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor. CONCLUSIONS Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.
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29
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Jiménez JV, Carrillo-Pérez DL, Rosado-Canto R, García-Juárez I, Torre A, Kershenobich D, Carrillo-Maravilla E. Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 2017; 62:1855-1871. [PMID: 28501971 DOI: 10.1007/s10620-017-4597-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/26/2017] [Indexed: 12/17/2022]
Abstract
Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
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Affiliation(s)
- José Víctor Jiménez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Diego Luis Carrillo-Pérez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Rodrigo Rosado-Canto
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - David Kershenobich
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Eduardo Carrillo-Maravilla
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico.
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30
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Leise MD, Findlay JY. Hyponatremia in the perioperative period: When and how to correct. Clin Liver Dis (Hoboken) 2017; 9:111-114. [PMID: 30992972 PMCID: PMC6467151 DOI: 10.1002/cld.630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/22/2016] [Accepted: 01/28/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michael D. Leise
- William J. von Liebig Center for Transplantation and Clinical Regeneration,Division of Gastroenterology & Hepatology
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31
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Sarici KB, Karakas S, Otan E, Ince V, Koc C, Koc S, Bayraktar H, Aydin C, Kayaalp C, Gungor S, Kablan Y, Yilmaz S. Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen? Transplant Proc 2017; 49:571-574. [PMID: 28340835 DOI: 10.1016/j.transproceed.2017.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation. METHODS In Inonu University's Liver Transplant Institute, 69 patients who made an emergency notice to the National Coordination Center for liver transplantation owing to FLF from January 2012 to December 2015 were included in the study. Patients were divided into 2 groups. Group 1 consisted of 52 patients who underwent liver transplantation and recovered normal brain function, and group 2 had 17 patients who underwent liver transplantation and did not recover normal brain function and had cerebral death. All patients were evaluated before surgery for clinical encephalopathy stage, light reflex, and convulsions. Groups were compared and assessed according to age (>40, 10-40 and <10 years), body mass index, etiologic factor, preoperative laboratory values, transplantation type, mortality, and encephalopathy level. Multivariate analysis was done for specific parameters. RESULTS Prothrombin time (PT), international normalized ratio (INR), and total bilirubin values were significantly different between the groups. There was no significant difference between the groups regarding ammonia and lactate levels. There was a statistically significant difference between the groups regarding sodium and potassium levels from serum electrolytes. However, the averages of both groups were within normal limits. pH and total bilirubin levels were meaningful for multivariate analysis. CONCLUSIONS HE reversibility, mortality, and morbidity are important in patients with HE who undergo liver transplantation. Therefore, West Haven clinical staging and serum INR, PT, and total bilirubin level may be helpful in predicting the reversibility of FLF patients with HE before liver transplantation. It was determined that West Haven encephalopathy grading is important in determining the reversibility of HE after transplantation in FLF; especially the probability of reversibility of stage 4 HE decreases significantly. High PT and INR levels, hyperbilirubinemia, and serum sodium and potassium concentrations were risk factors for the reversibility of HE in this study.
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Affiliation(s)
- K B Sarici
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey.
| | - S Karakas
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - E Otan
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - V Ince
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - C Koc
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - S Koc
- Department of Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - H Bayraktar
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - C Aydin
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - C Kayaalp
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
| | - S Gungor
- Department of Pediatric Neurology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Y Kablan
- Department of Neurology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - S Yilmaz
- Department of Surgery, Inonu University, Institute of Liver Transplantation, Malatya, Turkey
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Incidence and Predictors of Advanced Liver Fibrosis by a Validated Serum Biomarker in Liver Transplant Recipients. Can J Gastroenterol Hepatol 2017; 2017:4381864. [PMID: 28409147 PMCID: PMC5376470 DOI: 10.1155/2017/4381864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/13/2015] [Indexed: 12/29/2022] Open
Abstract
Background and Aims. Serum fibrosis biomarkers have shown good accuracy in the liver transplant (LT) population. We employed a simple serum biomarker to elucidate incidence and predictors of advanced fibrosis after LT over a long follow-up period. Methods. We included 440 consecutive patients who underwent LT between 1991 and 2013. Advanced liver fibrosis was defined as FIB-4 > 3.25 beyond 12 months after LT. Results. Over 2030.5 person-years (PY) of follow-up, 189 (43%) developed FIB-4 > 3.25, accounting for an incidence of 9.3/100 PY (95% confidence interval [CI], 8.1-10.7). Advanced fibrosis was predicted by chronic HCV infection (adjusted hazard ratio (aHR) = 3.96, 95% CI 2.92-5.36, p < 0.001), hypoalbuminemia (aHR = 2.31, 95% CI 1.72-3.09; p < 0.001), and hyponatremia (aHR = 1.48, 95% CI 1.09-2.01; p = 0.01). LT recipients with more than 1 predictor had a higher incidence of advanced fibrosis, the highest being when all 3 predictors coexisted (log-rank: p < 0.001). Conclusions. Chronic HCV infection, hypoalbuminemia, and hyponatremia predict progression to advanced liver fibrosis following LT. Patients with these risk factors should be serially monitored using noninvasive fibrosis biomarkers and prioritized for interventions.
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Pruinelli L, Monsen KA, Gross CR, Radosevich DM, Simon GJ, Westra BL. Predictors of Liver Transplant Patient Survival. Prog Transplant 2016; 27:98-106. [DOI: 10.1177/1526924816680099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient’s survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Data Source: Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014. Study Selection: Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation. Data Extraction: Predictors were extracted from 26 studies that met the inclusion criteria. Data Synthesis: Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions). Conclusions: The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.
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Affiliation(s)
| | - Karen A. Monsen
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia R. Gross
- School of Nursing and College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - David M. Radosevich
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - György J. Simon
- Department of Health Science Research, Mayo Clinic Rochester, Rochester, MN, USA
| | - Bonnie L. Westra
- School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
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34
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Györi GP, Silberhumer GR, Rahmel A, de Vries E, Soliman T, Zehetmayer S, Rogiers X, Berlakovich GA. Impact of dynamic changes in MELD score on survival after liver transplantation - a Eurotransplant registry analysis. Liver Int 2016; 36:1011-7. [PMID: 26814059 DOI: 10.1111/liv.13075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 01/14/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS With restricted numbers of available organs, futility in liver transplantation has to be avoided. The concept of dynamic changes in MELD score (DeltaMELD) has previously been shown to be a simple tool to identify patients with the greatest risk of death after transplantation. Aim was to validate this concept with the Eurotransplant (ET) database. METHODS A retrospective registry analysis was performed on all patients listed for liver transplantation within ET between 2006 and 2011. Patients <18 years of age, acute liver failure, malignancy and patients listed for retransplantation were excluded. Influence of MELD at listing (MELDon), MELD at transplantation (MELDoff), DeltaMELD, age, sex, underlying disease and time on the waiting list on overall survival after liver transplantation were evaluated. RESULTS A total of 16 821 patients were listed for liver transplantation, 8096 met the inclusion criteria. Age, MELD on and DeltaMELD showed significant influence on survival on the waiting list. Age and DeltaMELD showed influence on survival after liver transplantation, with DeltaMELD>10 showing a 1.6-fold increased risk of death. CONCLUSION The concept of DeltaMELD was validated in a large, prospective data set. It provides a simple tool to identify patients with increased risk of death after liver transplantation and might help improve long-term results.
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Affiliation(s)
- Georg P Györi
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Axel Rahmel
- Eurotransplant Foundation, Leiden, the Netherlands
| | | | - Thomas Soliman
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Sonja Zehetmayer
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Xavier Rogiers
- Department of Surgery and Transplantation, University Hospital and Medical School, Gent, Belgium
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Lange UG, Bucher JN, Schoenberg MB, Benzing C, Schmelzle M, Gradistanac T, Strocka S, Hau HM, Bartels M. Orthotopic liver transplantation for giant liver haemangioma: A case report. World J Transplant 2015; 5:354-359. [PMID: 26722664 PMCID: PMC4689947 DOI: 10.5500/wjt.v5.i4.354] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/24/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
In liver haemangiomas, the risk of complication rises with increasing size, and treatment can be obligatory. Here we present a case of a 46-year-old female who suffered from a giant haemangioma causing severe portal hypertension and vena cava compression, leading to therapy refractory ascites, hyponatremia and venostasis-associated thrombosis with pulmonary embolism. The patients did not experience tumour rupture or consumptive coagulopathy. Surgical resection was impossible because of steatosis of the non-affected liver. Orthotopic liver transplantation was identified as the only treatment option. The patient’s renal function remained stable even though progressive morbidity and organ allocation were improbable according to the patient’s lab model for end-stage liver disease (labMELD) score. Therefore, non-standard exception status was approved by the European organ allocation network “Eurotransplant”. The patient underwent successful orthotopic liver transplantation 16 mo after admission to our centre. Our case report indicates the underrepresentation of morbidity associated with refractory ascites in the labMELD-based transplant allocation system, and it indicates the necessity of promptly applying for non-standard exception status to enable transplantation in patients with a severe clinical condition but low labMELD score. Our case highlights the fact that liver transplantation should be considered early in patients with non-resectable, symptomatic benign liver tumours.
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36
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O'Leary JG, Orloff SL, Levitsky J, Martin P, Foley DP. Keeping high model for end-stage liver disease score liver transplantation candidates alive. Liver Transpl 2015; 21:1428-37. [PMID: 26335696 DOI: 10.1002/lt.24329] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/14/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023]
Abstract
As the mean Model for End-Stage Liver Disease (MELD) score at time of liver transplantation continues to increase, it is crucial to implement preemptive strategies to reduce wait-list mortality. We review the most common complications that arise in patients with a high MELD score in an effort to highlight strategies that can maximize survival and successful transplantation.
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Affiliation(s)
- Jacqueline G O'Leary
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.,Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ
| | - Susan L Orloff
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Department of Surgery, Oregon Health and Sciences University, Portland, OR
| | - Josh Levitsky
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Paul Martin
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Department of Medicine, University of Miami School of Medicine, Miami, FL
| | - David P Foley
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI.,Veterans Administration Surgical Services, William S. Middleton Memorial Hospital, Madison, WI
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37
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Predictors of Early Hospitalization After Deceased Donor Liver Transplantation. Dig Dis Sci 2015; 60:3242-7. [PMID: 26123837 PMCID: PMC4743740 DOI: 10.1007/s10620-015-3753-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/06/2015] [Indexed: 12/09/2022]
Abstract
UNLABELLED Hospitalizations after solid organ transplantation may affect patient outcomes. Identification of the factors attributed to them may decrease hospitalization rates, reduce overall cost, and improve post-transplant outcomes. We examined the risk factors for early hospitalization within 30 and 90 days after liver transplantation (LT). METHODS Data on all deceased donor LT recipients (age ≥18 years) transplanted between 2/28/2002-2/27/2007 and discharged alive from the index hospitalization within 30 days of LT were collected (N = 267). Patients were followed up until December 31, 2013. Logistic regression was used to identify the predictors of 30-day hospitalization, and linear regression was used to identify the factors associated with number of days hospitalized during 30- and 90-day hospitalization after LT. Renal risk index (RRI), a recently developed and validated risk score that accurately predicts the post-LT ESRD based upon recipient factors at LT, was computed using RRI calculator ( http://rri.med.umich.edu ). RESULTS One-third and more than half of the patients had at least one 30- and 90-day hospitalization, respectively. RRI decile (OR 1.12, P = 0.02) and serum sodium at LT (OR 0.90, P < 0.001) were independently associated with 30-day hospitalization after adjusting for MELD score. Serum creatinine at LT (β = 4.34, P = 0.001) and pre-LT admission days (β = 0.15, P = 0.027) affected the number of days hospitalized for 90-day hospitalization. RRI was also an independent predictor of post-LT mortality. CONCLUSION Early hospitalizations within 30 and 90 days after deceased donor LT are common. While all post-LT hospitalization cannot be prevented, efforts should be directed toward risk-based post-discharge care, and coordination of effective transitional care through ambulatory clinics. Implementation of such processes may attenuate early post-LT hospitalization and resource utilization and improve quality.
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38
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Variables Associated With the Risk of Early Death After Liver Transplantation at a Liver Transplant Unit in a University Hospital. Transplant Proc 2015; 47:1008-11. [DOI: 10.1016/j.transproceed.2015.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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39
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Biggins SW. Use of serum sodium for liver transplant graft allocation: a decade in the making, now is it ready for primetime? Liver Transpl 2015; 21:279-81. [PMID: 25641769 DOI: 10.1002/lt.24085] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/21/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, Anschutz Medical Campus, University of Colorado, Aurora, CO
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40
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Sharma P, Schaubel DE, Goodrich NP, Merion RM. Serum sodium and survival benefit of liver transplantation. Liver Transpl 2015; 21:308-13. [PMID: 25504743 PMCID: PMC4354811 DOI: 10.1002/lt.24063] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 11/30/2014] [Indexed: 12/13/2022]
Abstract
Hyponatremia is associated with elevated wait-list mortality among end-stage liver disease candidates for liver transplantation (LT). However, the effect of low serum sodium on the survival benefit of LT has not been examined. We sought to determine whether pretransplant hyponatremia is associated with an altered LT survival benefit. Data were obtained from the Scientific Registry of Transplant Recipients. The study population consisted of adults (age ≥ 18 years) placed on the waiting list for LT between January 1, 2005 and December 31, 2012 (n = 69,213). The effect of hyponatremia on the survival benefit was assessed via sequential stratification, an extension of Cox regression. Each transplant recipient was matched to appropriate candidates then active on the waiting list with the same Model for End-Stage Liver Disease (MELD) score and in the same donation service area. The focus of the analysis was the interaction between the serum sodium and the MELD score with respect to the survival benefit of LT; this was defined as the covariate-adjusted hazard ratio contrasting post-LT mortality and pre-LT mortality. The LT survival benefit increased significantly with decreasing serum sodium values when the MELD scores were >11. The survival benefit of LT was not affected by serum sodium for patients with MELD scores ≤ 11. In conclusion, the LT survival benefit (or lack thereof) is independent of serum sodium for patients with MELD scores ≤ 11. The increase in the survival benefit with decreasing serum sodium among patients with MELD scores > 11 is consistent with recently approved changes to the allocation system incorporating serum sodium.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | | | | | - Robert M. Merion
- Department of Surgery, University of Michigan, Ann Arbor, MI,Arbor Research Collaborative for Health, Ann Arbor, MI
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Hudcova J, Ruthazer R, Bonney I, Schumann R. Sodium Homeostasis During Liver Transplantation and Correlation with Outcomes. Anesth Analg 2014; 119:1420-8. [DOI: 10.1213/ane.0000000000000415] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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