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Dilutional Hyponatremia in Patients With Cirrhosis and Ascites
Almudena Porcel, MD;
Fernando Díaz, MD, PhD;
Paloma Rendón, MD;
Manuel Macías, MD;
Leopoldo Martín-Herrera, MD, PhD;
José A. Girón-González, MD, PhD
Arch Intern Med. 2002;162:323-328.
Objectives To analyze the predisposing factors, modifications of vasoactive systems,
and prognosis of patients with cirrhosis and hyponatremia.
Patients and Methods Fifty-four patients with hyponatremia (serum sodium level of <130
mEq/L after 5 days of hyponatremic diet and no diuretic therapy). Twenty cirrhotic
patients served as controls. We measured plasma renin activity and levels
of plasma aldosterone, norepinephrine, and antidiuretic hormone. Follow-up
identified the development of hepatorenal syndrome and death.
Results A higher percentage of patients with hyponatremia had decreased liver
size, higher levels of plasma renin activity, and higher serum concentrations
of aldosterone and norepinephrine. Renal insufficiency was detected in 31
of them (57%). Precipitating factors (hemorrhage or infections) were detected
in 27 patients (50%). Incidence of hepatorenal syndrome and death were higher
in patients with spontaneous development of hyponatremia (n = 23 [85%] and
n = 25 [93%], respectively) than in patients with precipitating factors (n
= 15 [56%] and n = 12 [44%], respectively) and cirrhotic controls (n = 1 [5%]
and n = 5 [25%], respectively) (P<.001). Results
of multivariate analysis showed that Child-Pugh index, presence of hepatocarcinoma,
and serum concentration of urea were associated with mortality. After excluding
those patients with kidney failure at the time of admission, only Child-Pugh
index and norepinephrine concentrations were independent predictors of mortality.
Conclusions Hyponatremia is an alteration in patients with advanced liver disease.
Although survival is significantly reduced in patients with spontaneous development
of hyponatremia, a reduced sodium concentration cannot be considered as a
independent predictor of the risk for death.
From the Servicio de Aparato Digestivo (Drs Porcel, Díaz, Rendón,
Macías, and Martín-Herrera) and the Servicio de Medicina Interna
(Dr Girón-González), Hospital Universitario Puerta del Mar,
Cádiz, Spain.
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