Water, electrolyte, acid–base, and trace elements alterations in cirrhotic patients

Hyponatremia and malnutrition: a comprehensive review

BACKGROUND

Hyponatremia (serum sodium lower than 135 mmol/L) is the most frequent electrolyte alteration diagnosed in medical practice. It has deleterious clinical effects, being an independent predictor of mortality. Malnutrition encompasses pathological states caused by both nutrients excess and deficiency, being frequently documented in chronic kidney disease patients. In addition, chronic hyponatremia promotes adiposity loss and sarcopenia, while malnutrition can induce hyponatremia. This pathological interaction is mediated by four main mechanisms: altered electrolyte body composition (low sodium, low potassium, low phosphorus, or high-water body content), systemic inflammation (cytokines increase), hormonal mechanisms (renin-angiotensin-aldosterone system activation, vasopressin release), and anorexia (primary or secondary).

CONCLUSION

Malnutrition can induce hyponatremia through hydro-electrolytic, hormonal, inflammatory, or nutritional behavior changes; while hyponatremia per se can induce malnutrition, so there is a pathophysiological feedback between both conditions.

Decaying kidney function during cirrhosis correlates with remodeling of distal colon aldosterone target gene expression

Liver cirrhosis is associated to circulatory abnormalities leading to hypovolemia and stimulation of the renin-angiotensin-aldosterone system (RAAS). Advanced stages of the disease cause renal failure, impairing K+ and Na+ homeostasis. It has been proposed that the distal colon undergoes functional remodeling during renal failure, in particular by aldosterone-driven increased K+ excretion. In this study, we compared the transcriptional response of aldosterone target genes in the rat distal colon under two models of increased circulating aldosterone (one with concomitant RAAS activation) and in a model of secondary hyperaldosteronism induced by cirrhosis. The expression of a subset of these genes was also tested in distal colon biopsies from control subjects or patients with cirrhosis with varying levels of disease progression and treated or not with mineralocorticoid receptor inhibitor spironolactone. We examined known aldosterone-regulated transcripts involved in corticosteroid signaling and transepithelial ion transport. In addition, we included aldosterone-regulated genes related to cell proliferation. Our comparison revealed multiple aldosterone target genes upregulated in the rat distal colon during decompensated cirrhosis. Epithelial Na+ channel β and γ subunit expression correlated positively with plasma aldosterone concentration and negatively with glomerular filtration rate. Patients with cirrhosis showed increased expression of 11-β-hydroxysteroid-dehydrogenase 2 (11βHSD2), which was reverted by spironolactone treatment, suggesting a sensitization of the distal colon to aldosterone action. In summary, our data show that decaying kidney function during cirrhosis progression toward a decompensated state with hypovolemia correlates with remodeling of distal colon ion transporter expression, supporting a role for aldosterone in the process.NEW & NOTEWORTHY Liver cirrhosis progression significantly alters ion transporter subunit expression in the rat distal colon, a change that correlated well with declining kidney function and the severity of the disease. Our data suggest that the steroid hormone aldosterone participates in this homeostatic response to maintain electrolyte balance.

Evaluation and management of emergencies in the patient with cirrhosis

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.

Evaluation and management of emergencies in the patient with cirrhosis

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.

Lower serum chloride concentrations are associated with increased risk of mortality in critically ill cirrhotic patients: an analysis of the MIMIC-III database

Background

Cirrhosis can be complicated by electrolyte abnormalities, but the major focus has been concentrated on the clinical significance of serum sodium levels. Emerging studies have identified hypochloremia as an independent prognostic marker in patients with chronic heart failure and chronic kidney disease. The aim of this study was to investigate whether serum chloride levels were associated with mortality of critically ill cirrhotic patients.

Methods

Critically ill cirrhotic patients were identified from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was ICU mortality. Logistic regression was used to explore the association between serum chloride levels and ICU mortality. The area under the receiver operating characteristic curves (AUC) was used to assess the performance of serum chloride levels for predicting ICU mortality.

Results

A total of 1216 critically ill cirrhotic patients were enrolled in this study. The overall ICU mortality rate was 18.8%. Patients with hypochloremia had a higher ICU mortality than those with non-hypochloremia (34.2% vs. 15.8%; p < 0.001). After multivariable risk adjustment for age, gender, ethnicity, chloride, sodium, Model for End-stage Liver Disease score, Sequential Organ Failure Assessment score, Elixhauser comorbidity index, mechanical ventilation, vasopressors, renal replacement therapy, acute kidney injury, hemoglobin, platelet, and white blood cell, serum chloride levels remained independently associated with ICU mortality (OR 0.94; 95% CI 0.91–0.98; p = 0.002) in contrast to serum sodium levels, which were no longer significant (OR 1.03; 95% CI 0.99–1.08; p = 0.119). The AUC of serum chloride levels (AUC, 0.600; 95% CI 0.556–0.643) for ICU mortality was statistically higher than that of serum sodium levels (AUC, 0.544; 95% CI 0.499–0.590) (p < 0.001).

Conclusions

In critically ill cirrhotic patients, serum chloride levels are independently and inversely associated with ICU mortality, thus highlighting the prognostic role of serum chloride levels which are largely overlooked.

Risk Factors for 90-day Readmissions With Fluid and Electrolyte Disorders Following Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study of the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database.

OBJECTIVE

To identify risk factors for 30- and 90-day readmission due to fluid and electrolyte disorders following posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

Thirty- and 90-day readmission rates are important quality and outcome measures for hospitals and physicians. These measures have been tied to financial penalties for abnormally high rates of readmission. Furthermore, complex and high cost surgeries have been increasingly reimbursed in the form of bundled disease resource group payments, where any treatment within 90-day postdischarge is covered within the original bundled payment scheme.

METHODS

A total of 65,121 patients in the Healthcare Cost and Utilization Project Nationwide Readmissions Database met our inclusion criteria, of which 1128 patients (1.7%) were readmitted within 30 days, and 1669 patients (2.6%) were readmitted within 90 days due to fluid and electrolyte abnormalities. A bivariate analysis was performed to compare baseline characteristics between patients readmitted with fluid and electrolyte disorders and the remainder of the cohort. A multivariate regression analysis was then performed to identify independent risk factors for readmission due to fluid and electrolyte disorders at 30 and 90 days.

RESULTS

The strongest independent predictors of 30-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and drug use disorder. The five strongest predictors of 90-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and fluid and electrolyte disorders.

CONCLUSION

Patients with baseline liver disease, previously diagnosed fluid and electrolyte disorders, age older than 55 years, or drug use disorders are at higher risk for readmissions with fluid and electrolyte disorders following posterior lumbar fusion. Close monitoring of fluid and electrolyte balance in the perioperative period is essential to decrease complications and reduce unplanned readmissions.

LEVEL OF EVIDENCE

3.