How to manage hyponatremia and ascites in patients?

Management of Hyponatremia and Ascites in Cirrhosis

The management of hyponatremia in cirrhotic patients with ascites should be based on serum sodium levels, with fluid restriction reserved only for those with severe hyponatraemia (serum sodium <125 mmol/L) who are clinically hypervolaemic. 1

Diagnostic Approach

• Determine severity of hyponatremia based on serum sodium levels:
  • Mild: 126-135 mmol/L
  • Moderate: 121-125 mmol/L
  • Severe: ≤120 mmol/L
• Assess volume status (hypovolemic vs. hypervolemic)
• Check renal function (serum creatinine)
• Evaluate ascites severity (mild, moderate, or severe/tense)

Management Algorithm Based on Serum Sodium Levels

For Serum Sodium 126-135 mmol/L with Normal Renal Function

• Continue diuretic therapy if already prescribed
• Monitor serum electrolytes closely
• Do not restrict water intake 1
• Implement dietary salt restriction to 90 mmol/day (5.2 g salt/day) 1

For Serum Sodium 121-125 mmol/L with Normal Renal Function

• Opinion is divided on management approach:
  • International consensus suggests continuing diuretics
  • More cautious approach is to stop diuretics 1
• Monitor electrolytes closely
• Maintain dietary salt restriction

For Serum Sodium 121-125 mmol/L with Elevated Creatinine

• Stop diuretics immediately
• Provide volume expansion with colloid or saline 1
• Monitor sodium and renal function closely

For Serum Sodium ≤120 mmol/L

• Stop diuretics immediately
• Volume expansion with colloid (haemaccel, gelofusine) or saline 1
• Avoid increasing serum sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis 1

Specific Management Strategies

Dietary Management

• Implement moderate salt restriction (90 mmol/day or 5.2 g salt/day) 1
• Recommend no-added salt diet with avoidance of pre-prepared meals
• Provide nutritional counseling on sodium content in diet 1

Diuretic Management

• For first presentation of moderate ascites:
  • Start with spironolactone monotherapy (starting dose 100 mg, increased up to 400 mg) 1
• For recurrent severe ascites:
  • Combination therapy with spironolactone (100-400 mg) and furosemide (40-160 mg) 1
• Monitor for adverse events, which may require dose reduction or discontinuation in nearly half of patients 1

Fluid Restriction

• Water restriction should be reserved only for patients with severe hyponatremia (serum sodium <125 mmol/L) who are clinically hypervolemic 1
• Restrict to 1-1.5 L/day when indicated 1
• Avoid fluid restriction in patients with uncomplicated ascites 1

Hypertonic Saline

• Reserve 3% sodium chloride for severely symptomatic patients with acute hyponatremia 1
• Correct serum sodium slowly to avoid central pontine myelinolysis
• Limit correction to 5 mmol/L in first hour and 8-10 mmol/L per 24 hours 1

Management of Refractory Cases

Large Volume Paracentesis (LVP)

• Consider for tense or refractory ascites
• Administer albumin (20% or 25% solution) at 8 g/L of ascites removed after paracentesis of >5 L 1
• For paracentesis <5 L, consider albumin in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1

Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

• Consider for refractory ascites 1
• Use caution in patients with age >70 years, elevated bilirubin, low platelet count, or other contraindications

Common Pitfalls and Caveats

1. Avoid water restriction in mild hyponatremia - This is ineffective and may worsen the underlying pathophysiology by exacerbating central hypovolemia 1

2. Avoid rapid correction of hyponatremia - Can lead to central pontine myelinolysis, especially in patients with liver disease

3. Recognize the controversy in management - There is debate about the best approach to hyponatremia in cirrhosis, with some experts favoring plasma expansion rather than water restriction 1

4. Monitor for diuretic complications - Diuretics can worsen hyponatremia and renal function in some patients

5. Consider the pathophysiology - Hyponatremia in cirrhosis is often due to non-osmotic secretion of ADH driven by effective hypovolemia despite total body fluid overload 1, 2

By following this structured approach based on serum sodium levels and renal function, clinicians can effectively manage the challenging combination of hyponatremia and ascites in patients with cirrhosis.