Risk Factors for Central Pontine and Extrapontine Myelinolysis After Liver Transplantation

Crivellin, Chiara; Cagnin, Annachiara; Manara, Renzo; Boccagni, Patrizia; Cillo, Umberto; Feltracco, Paolo; Barbieri, Stefania; Ferrarese, Alberto; Germani, Giacomo; Russo, Francesco Paolo; Burra, Patrizia; Senzolo, Marco

doi:10.1097/tp.0000000000000496

Cited by 43 publications

(49 citation statements)

References 51 publications

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“…We found that further chart review was required to ascertain rapid correction in some patients with incident osmotic demyelination, because outpatient serum sodium values from outside hospitals were available in some progress notes, and two patients had sodium correction .8 mEq/L over a 24-hour period after day 1. Osmotic demyelination can also occur in other settings, such as hyperosmolar hyperglycemia, hyperammonemia, hypoxia, severe liver disease, and chronic alcoholism, in the absence of documented rapid sodium correction (24)(25)(26)(27)(28)(29). The exact mechanism of demyelination in the setting of alcohol abuse is not entirely clear but could be related to direct neurotoxicity of alcohol, malnutrition, or underlying liver disease (26).…”

Section: Discussionmentioning

confidence: 99%

Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia

George

Zafar

Bucaloiu

et al. 2018

CJASN

103

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Background and objectives Rapid correction of severe hyponatremia can result in serious neurologic complications, including osmotic demyelination. Few data exist on incidence and risk factors of rapid correction or osmotic demyelination. Design, setting, participants, & measurements In a retrospective cohort of 1490 patients admitted with serum sodium ,120 mEq/L to seven hospitals in the Geisinger Health System from 2001 to 2017, we examined the incidence and risk factors of rapid correction and osmotic demyelination. Rapid correction was defined as serum sodium increase of .8 mEq/L at 24 hours. Osmotic demyelination was determined by manual chart review of all available brain magnetic resonance imaging reports. Results Mean age was 66 years old (SD=15), 55% were women, and 67% had prior hyponatremia (last outpatient sodium ,135 mEq/L). Median change in serum sodium at 24 hours was 6.8 mEq/L (interquartile range, 3.4-10.2), and 606 patients (41%) had rapid correction at 24 hours. Younger age, being a woman, schizophrenia, lower Charlson comorbidity index, lower presentation serum sodium, and urine sodium ,30 mEq/L were associated with greater risk of rapid correction. Prior hyponatremia, outpatient aldosterone antagonist use, and treatment at an academic center were associated with lower risk of rapid correction. A total of 295 (20%) patients underwent brain magnetic resonance imaging on or after admission, with nine (0.6%) patients showing radiologic evidence of osmotic demyelination. Eight (0.5%) patients had incident osmotic demyelination, of whom five (63%) had beer potomania, five (63%) had hypokalemia, and seven (88%) had sodium increase .8 mEq/L over a 24-hour period before magnetic resonance imaging. Five patients with osmotic demyelination had apparent neurologic recovery. Conclusions Among patients presenting with severe hyponatremia, rapid correction occurred in 41%; nearly all patients with incident osmotic demyelination had a documented episode of rapid correction.

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Section: Discussionmentioning

confidence: 99%

Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia

George

Zafar

Bucaloiu

et al. 2018

CJASN

103

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“…However, ODS is uncommon and occurs in <1.5% of individuals. (9)(10)(11)(12) The risk of ODS appears to be highest in cases where the serum sodium increases at a rate of >12 mEq/L within 24 hours. (13) Guidelines recommend a rate of correction of ≤8-10 mEq/L in the first 24 hours and ≤18 mEq/L in the first 48 hours.…”

Section: Discussionmentioning

confidence: 99%

“…(25) It typically presents approximately 2-7 days after rapid serum sodium correction. The incidence of ODS ranges from 0.5% to 1.5% in the context of LT. (9,12,26) The main risk factor for ODS is the rapid correction of chronic hyponatremia in patients with or without LT. Severe hypophosphatemia, severe hypokalemia, and possibly alcoholism and male sex are also risk factors.…”

Section: Managementmentioning

confidence: 99%

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Hyponatremia in Cirrhosis: Implications for Liver Transplantation

Leise¹,

Cárdenas

2018

Liver Transpl

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Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. Overcorrection of hyponatremia before LT or perioperatively can lead to the devastating neurologic condition known as osmotic demyelination syndrome, which is often irreversible and fatal. Therefore, the most important tenet of hyponatremia is to avoid correcting the serum sodium by ≥8 mEq/L in a 24-hour period. Treatment of hyponatremia is highly challenging. The vast majority of patients with cirrhosis have chronic hypervolemic hyponatremia. Fluid restriction increases serum sodium levels, but tolerance and compliance are significant barriers. Diuretic withdrawal is helpful but contributes to worsening fluid overload. There are limited data to support use of intravenous concentrated albumin solutions. The use of the arginine vasopressin antagonists ("vaptans") is contentious; however, they may have a limited role. Risk factors for intraoperative overcorrection of serum sodium include increased utilization of packed red blood cell and fresh frozen plasma transfusions, which are often unavoidable. Intraoperative management is evolving, and more data are needed in regard to the use of sodium-reduced continuous venovenous hemofiltration and the use of trishydroxymethylaminomethane (Tris) to avoid excess sodium rebound. A thorough discussion of the current treatment options before and during LT is given in this review.

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“…The associated hemodynamic instability and brain edema (with increased intracranial pressure) can result in complications such as arrhythmia, central pontine myelinolysis, brain stem herniation, and graft failure-not the intended end result of a surgery meant to restore organ function. 4,5 Many centres have now reported that intraoperative renal replacement therapy (IoRRT) during LT may reduce the incidence of these potential complications. [6][7][8][9][10] Various modalities of renal replacement therapy (RRT) have been used for IoRRT in this context.…”

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confidence: 99%