Can chronic hyponatremia cause altered mental status in a patient with cirrhosis and what is the appropriate management?

From the Guidelines

Chronic hyponatremia can cause altered mental status in patients with cirrhosis, and management requires careful correction to avoid osmotic demyelination syndrome. The patient's hyponatremia, with a current sodium level of 124 mmol/L, is likely contributing to her altered mental status, as hyponatremia can lead to symptoms such as confusion, lethargy, and disorientation, especially when sodium levels fall below 130 mmol/L 1. According to the most recent guidelines, for patients with chronic hyponatremia, the goal rate of increase of serum sodium is 4-6 mEq/L per 24-hour period, not to exceed 8 mEq/L per 24-hour period to ameliorate the risk of osmotic demyelination syndrome (ODS) 1. Key management strategies include:

• Fluid restriction to 1-1.5 L/day for asymptomatic or mildly symptomatic patients
• Hypertonic saline (3% NaCl) for patients with more severe symptoms, with careful monitoring of sodium correction
• Vasopressin receptor antagonists like tolvaptan, used at starting doses of 15 mg daily, with close monitoring for rapid sodium correction
• Albumin infusion (20-40 g/day) may help in patients with ascites
• Discontinuation of diuretics if contributing to hyponatremia It is essential to address the underlying pathophysiology, which involves impaired free water excretion due to increased antidiuretic hormone levels and decreased effective circulating volume in cirrhosis, to improve mental status by restoring proper neuronal function and reducing cerebral edema 1. Additionally, it is crucial to investigate other potential causes of altered mental status, such as hepatic encephalopathy, infections, and electrolyte disorders, as these can coexist with hyponatremia and worsen the patient's condition 1.

From the Research

Altered Mental Status in Cirrhosis

• The patient's altered mental status could be due to various causes, including hepatic encephalopathy (HE), sepsis/infection, metabolic disorders, or other factors 2.
• Chronic hyponatremia, as seen in this patient, can contribute to altered mental status and is associated with increased morbidity and mortality in cirrhotic patients 3, 4.

Role of Hyponatremia in Altered Mental Status

• Hyponatremia can affect brain function and predispose to hepatic encephalopathy, making it a potential contributing factor to the patient's altered mental status 3, 4.
• The severity of hyponatremia is directly related to the deterioration in terms of grades of HE, with lower sodium levels associated with higher grades of HE 4.

Management of Hyponatremia and Altered Mental Status

• Gradual sodium correction of no more than 8-12 meq/L per day is recommended to avoid central myelinolysis syndrome 5.
• Free water restriction and increased dietary sodium are reasonable, cost-effective treatment options for chronic hyponatremia 5.
• Management of hepatic encephalopathy, including lactulose and rifaximin, may also be necessary to address the patient's altered mental status 5, 6.

Further Evaluation and Management

• A thorough history, physical, and neurologic examination is essential to identify other potential causes of altered mental status in this patient 5.
• Laboratory tests, including blood and urine cultures, should be evaluated to rule out sepsis or other infections 2.
• Consideration of liver transplantation may be necessary for patients with advanced liver disease and hepatic encephalopathy 5.