CRRT to Correct Severe Hyponatremia in AKI Prior to Liver Transplant

Austin, Texas—In patients receiving a liver transplant, preoperative hyponatremia and rapid perioperative shifts in serum sodium, outcomes postoperatively may be complicated, worsening outcomes. Due to the risk of hepatic encephalopathy and osmotic demyelination syndrome (ODS), serum sodium level <120 mEq/L is considered a contraindication to liver transplantation. Pretransplant management of cirrhotic patients to prevent and safely correct severe hyponatremia is critical. Murad Kheetan, MD, presented a case report of a cirrhotic patient prior to liver transplantation; continuous renal replacement therapy (CRRT) was used to correct severe hyponatremia in acute kidney injury (AKI) prior to the liver transplant. The case was described during a poster session at the NKF 2018u Spring Clinical Meetings in a poster titled Continuous Renal Replacement Therapy for Correction of Severe Hyponatremia in a Cirrhotic Patient with Acute Kidney Injury Prior to Liver Transplantation.

The 45-year-old female with decompensated cirrhosis presented with worsening ascites and hyponatremia. The patient was transferred to the intensive care unit when she developed AKI from hypotension and rectus sheath hematoma. Despite therapy, her condition worsened and her status for liver transplantation was listed as 1A. Nephrology was consulted for anuric AKI and hyponatremia; her serum sodium level was 115 mEq/l.

CRRT was initiated to slowly correct hyponatremia (< 6 to 0 mEq/L in 24 hours) in the setting of AKI as a bridge to liver transplantation. Bicarbonate-based solutions (sodium 140 mEq/LK, HCO3 35 mEq/L, potassium 4 mEq/L, calcium 3 mEq/L) were used to initiate continuous veno-venous hemodiafiltration (CVVHDF), given as both prefilter replacement fluid at 1 liter per hour and dialysate at 1 L per hour. D5W was given as postfilter replalcement filter at 250 mL per hour.

The prescribed dose of CVVHDF was 35 mL/kg per hour. After 24 hours, serum sodium slowly rose to 123 mEq/L. Subsequently, the postfilter replacement filter was reduced to 100 mL per hour; serum sodium increased to 130 mEq/L by the following 24 hours. Within 72 hours of initiation of CRRT, the patient underwent successful liver transplantation with intraoperative CRRT. At six days after liver transplantation, CRRT was discontinued and the patient was transferred to the floor with recovered renal function.

In their summary, the researchers said, “This case demonstrates successful use of CRRT to correct severe hyponatremia as a bridge to liver transplant in a cirrhotic patient with AKI. The rate of sodium rise is determined by both replacement fluid/dialysate flow rate and sodium composition. At a controlled rate of increase, the serum sodium level can be normalized without risk of ODS.”

Source: Kheetan M, Tolwani AJ. Continuous renal replacement therapy for correction of severe hyponatremia in a cirrhotic patient with acute kidney injury prior to liver transplantation. Abstract of a poster presented at the National Kidney Foundation 2018 Spring Clinical Meetings, April 10-14, 2018, Austin, Texas.