How to manage acute alcoholic hepatitis with severe hyponatremia?

From the Guidelines

Management of acute alcoholic hepatitis with severe hyponatremia (Na 117) requires a comprehensive approach addressing both conditions simultaneously. Initial treatment involves alcohol cessation, nutritional support with high-calorie (2000-3000 kcal/day) protein-rich diets, and thiamine supplementation (100mg IV daily for 3-5 days, then oral) 1. For severe alcoholic hepatitis (Maddrey's Discriminant Function >32), prednisolone 40mg daily for 28 days is recommended, with assessment after 7 days using the Lille score to determine continuation 1. Severe hyponatremia (serum sodium <125 mEq/L) requires careful correction at a rate not exceeding 8-10 mEq/L in 24 hours to prevent osmotic demyelination syndrome. Fluid restriction to 1-1.5L/day is essential, with hypertonic saline (3%) reserved for severe symptomatic cases, administered at 0.5-2 mL/kg/hour with frequent monitoring. Underlying causes like diuretics should be discontinued, and tolvaptan may be considered in euvolemic hyponatremia. Concurrent management includes prophylactic antibiotics for infection prevention, proton pump inhibitors for GI bleeding risk, and close monitoring of renal function, electrolytes, and hepatic encephalopathy. This approach addresses both the liver inflammation and the dangerous electrolyte imbalance that can lead to neurological complications if not properly managed. Some key points to consider in the management include:

• The use of the Lille score to assess response to corticosteroid therapy and guide treatment decisions 1
• The importance of early identification and treatment of infections, which are common in patients with severe alcoholic hepatitis 1
• The need for careful monitoring of patients with severe alcoholic hepatitis, including regular assessment of liver function, renal function, and electrolytes 1
• The consideration of liver transplantation in selected patients with severe alcoholic hepatitis who do not respond to medical therapy 1

From the Research

Management of Acute Alcoholic Hepatitis with Severe Hyponatremia

• The management of acute alcoholic hepatitis with severe hyponatremia involves addressing both the liver condition and the electrolyte imbalance 2.
• Severe hyponatremia is defined as a sodium concentration of less than 125 mEq per L, and it can cause severe symptoms such as delirium, confusion, impaired consciousness, ataxia, seizures, and rarely, brain herniation and death 2.
• Patients with severe hyponatremia and acute alcoholic hepatitis require intensive management, including emergency infusions with 3% hypertonic saline if they have severe symptoms 2.
• The use of pentoxifylline or prednisolone may be considered in the management of severe alcoholic hepatitis, but their benefit in patients with severe hyponatremia is not well established 3, 4, 5.
• Pentoxifylline has been shown to reduce the incidence of fatal hepatorenal syndrome in severe alcoholic hepatitis, but it does not appear to have a significant survival benefit 4.
• Prednisolone may be associated with a reduction in 28-day mortality in patients with severe alcoholic hepatitis, but it does not improve outcomes at 90 days or 1 year 5.

Treatment of Hyponatremia

• The treatment of hyponatremia depends on the underlying cause and the patient's volume status 2.
• Hypovolemic hyponatremia is treated with normal saline infusions, while euvolemic hyponatremia is treated with free water restriction or the use of salt tablets or intravenous vaptans 2.
• Hypervolemic hyponatremia is treated primarily by managing the underlying cause, such as heart failure or cirrhosis, and free water restriction 2.
• The correction of sodium concentration should be done carefully to avoid overly rapid correction, which can cause osmotic demyelination syndrome 2.

Considerations in Acute Alcoholic Hepatitis

• The management of acute alcoholic hepatitis requires a comprehensive approach, including abstinence from alcohol, nutritional support, and vigorous management of complications 6.
• The use of corticosteroids, such as prednisolone, may be considered in patients with severe disease, but their benefit is not well established 6, 5.
• Pentoxifylline may be considered as an alternative to corticosteroids in patients with severe alcoholic hepatitis, but its benefit is not well established 4, 5.