Management of Infections with Hyponatremia

Diagnosis and Evaluation

The American Association for the Study of Liver Diseases recommends that hyponatremia (serum sodium <135 mmol/L) be evaluated based on volume status and serum osmolality 2
In patients with liver cirrhosis and ascites, a decrease in serum sodium concentration to less than 130 mmol/L is often due to dilutional hyponatremia 3
Determination of serum and urine osmolality, urine electrolytes, and assessment of extravascular fluid volume are important to determine the underlying cause of hyponatremia 2

Hyponatremia is associated with increased mortality in patients with liver cirrhosis and ascites 3
A decrease in serum sodium concentration below 130 mmol/L significantly impairs quality of life due to dietary restrictions for ascites control and impaired cognitive function 3
Patients with hyponatremia are more likely to develop spontaneous bacterial peritonitis, have a higher risk of hepatorenal syndrome, and have a poorer prognosis 3

For mild hyponatremia (Na 126-135 mmol/L), no specific treatment is required other than monitoring and water restriction 1
For moderate hyponatremia (Na 120-125 mmol/L), water restriction to 1000 ml/day and discontinuation of diuretics are recommended 1
For severe hyponatremia (Na <120 mmol/L), stricter water restriction and albumin infusion are recommended 1

Spontaneous bacterial peritonitis (SBP) occurs in 20-30% of patients with cirrhotic ascites and has a mortality rate of approximately 20% 3
SBP can be diagnosed if the number of polymorphonuclear leukocytes (PMN) in ascites is ≥ 250/mm³ without an obvious intra-abdominal infection 3

Vasopressin receptor antagonists (Vaptane) can be used to control ascites in cirrhosis, but with a warning for potential liver dysfunction 3
Tolvaptan should be used with caution and only for a short period (≤30 days) 1

In patients with severe symptoms, serum sodium should be monitored every 2 hours during the initial correction 2
Correction rate should not exceed 8 mmol/L in 24 hours to avoid osmotic demyelination syndrome 1, 2
Severe hyponatremia (<120 mmol/L) at the time of liver transplantation increases the risk of osmotic demyelination syndrome 1