From the Guidelines
Hyponatremia in patients with hepatic steatosis should be managed with careful consideration of the underlying liver disease, and treatment should focus on correcting sodium levels while avoiding rapid correction to prevent osmotic demyelination syndrome, with a goal rate of increase of serum sodium of 4-6 mEq/L per 24-hour period, not to exceed 8 mEq/L per 24-hour period, as recommended by the American Association for the Study of Liver Diseases in 2021 1.
Pathophysiology and Definition
Hyponatremia is a common condition in patients with advanced liver disease, including those with hepatic steatosis, and is defined as a serum sodium concentration lower than 130 mmol/L, although reductions below 135 mmol/L should also be considered, as stated in the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis in 2018 1.
Treatment Approach
The primary treatment approach involves addressing the underlying liver disease while carefully managing sodium levels.
- For mild hyponatremia (126-135 mEq/L), no specific management is required apart from monitoring and water restriction to 1,000 mL/day 1.
- For moderate hyponatremia (120-125 mEq/L), water restriction to 1,000 mL/day and cessation of diuretics is recommended 1.
- For severe hyponatremia (<120 mEq/L), a more severe restriction of water intake with albumin infusion is recommended 1.
Use of Vasopressin Receptor Antagonists
The use of vasopressin receptor antagonists, such as tolvaptan, should be used with caution only for a short term (≤30 days), as recommended by the American Association for the Study of Liver Diseases in 2021 1.
Correction of Hyponatremia
When correction of chronic hyponatremia is indicated in patients with cirrhosis, 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, as recommended by the American Association for the Study of Liver Diseases in 2021 1.
From the Research
Hyponatremia and Hepatic Steatosis
- Hyponatremia is a complication in patients with decompensated cirrhosis, and it is an important prognostic indicator in those with cirrhosis 2.
- Hepatic steatosis is defined as intrahepatic fat of at least 5% of liver weight, and it is associated with obesity, type 2 diabetes, and dyslipidemia 3.
- The pathogenesis of hepatic steatosis involves the accumulation of intrahepatic fat due to increased flux of fatty acids to the liver, increased de novo lipogenesis, and/or reduced clearance through β-oxidation or very-low-density lipoprotein secretion 3.
- Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease in the United States, affecting up to 30% of adults, and it can progress to steatohepatitis (nonalcoholic steatohepatitis), which can result in cirrhosis 4, 5.
- There is no direct evidence linking hyponatremia and hepatic steatosis, but both conditions are related to liver disease and can have significant clinical implications 6, 2, 3, 4, 5.
Clinical Implications
- Hyponatremia can lead to complications such as hepatic encephalopathy, and its management is crucial in patients with decompensated cirrhosis 2.
- Hepatic steatosis can lead to liver metabolic dysfunction, inflammation, and advanced forms of nonalcoholic fatty liver disease, and its prevention and treatment are important to reduce the risk of progression to cirrhosis 3, 5.
- The diagnosis and management of NAFLD involve identifying patients at risk, excluding other causes of liver disease, and using noninvasive tests to assess the presence of fibrosis 5.
- Weight loss through diet and exercise is the primary treatment for NAFLD, and other treatments such as bariatric surgery, vitamin E supplements, and pharmacologic therapy may be considered in certain cases 5.