2023-07-06 14:51:51
#Hepatology Liver #Cirrhosis Complications , Hyponatremia
خلصنا اول Complication من ال Cirrhosis اللي هو ال Ascites
هنشوف ان شاء الله تاني Complication بيصير مع مريض ال cirrhosis وهو ال Hyponatremia ..
مريض ال Cirrhosis خاصة ال Advanced بيقل عنده ال Na لأقل من 130mmol/L
وممكن تكون حاجه من اتنين :
Hypervolemic Hyponatremia ( Most common)
والسبب الرئيسي هو ال
Extracellular Fluid Volume expansion
بسبب زيادة ال ADH فهتزيد ال H2O Absorption
وبيكون المريض عنده Ascites و edema
او ممكن يحصل بسبب hypotonic fluid ( 5%Dextrose)
Hypovolemic Hyponatremia
غالبا بيكون مش مصحوب ب edema ولا Ascites
وسببه هو ال prolonged Negative Sodium balance
With Marked loss of Extracellular Fluid often to excessive Diuretic Therapy ..
Management of Hyponatremia in pateint With Cirrhosis :
ما في Evidence كفاية تقلي عند اي قيمة لل Na هعالج المريض
لكن بشكل عام لو قل ال Serum sodium عن 130 بنعالج المريض
في حالات ال Hypovolemic Hyponatremia فالحل اني ازود ال plasma volume باستخدام Normal Saline واصلح سبب ال Hypovolemia
في حالات ال Hypervolemic Hyponatremia
Non Osmotic Fluid Restriction is helpful in preventing Further decrease in serum sodium level but is seldem effective in Improving Natremia
طيب هل بنفع استخدم ال Hypertonic NacL في حالات ال
Hypervolemic HypoNa
ال Hypertonic Nacl بيعمل Enhancing لل Volume Overload ف بتسوأ حاله ال Ascites وال Edema
عشان هيك استخدامه هيكون limited للحالات التالية :
Sever Symptomatic Hyponatremia
وهم المرضى اللي بيكون عنده Life Threatening Complication
زي Cardio-respiratory Distress او Seizures او coma
او حالات ال Abnormal and deep somnoless
Sever Hyponatremia in patients who will have Liver Transplantation in Few days
في أي حاله من الحالات السابقه وقررنا نعطي
Hypertonic Nacl
ممنوع اعمل تصحيح للصوديوم بشكل سريع أو Completed
لمنع ال Risk لحدوث ال central Pontine Myeilinolysis
In practice, after an initial rapid correction aimed at attenuating clinical symptoms (5 mmol/L in the first hour), serum sodium concentration should not increase more than 8mmol/L per day
ال Albumin Infusion ممكن نستخدمه في حالات
ال Hypervolemic HypoNa لتصحيح ال serum Sodium
ولكن لسه ما عليه دراسات كافية
طيب هل ممكن نستخدم ال Vaptans لتصحيح ال Na
ال Vaptans هي الادويه اللي بتشتغل ك Antagonist لل
V2 Receptor ( Arginine Vasopressin )
الموجوده بال Collecting duct وهتمنع شغل ال ADH
بالتالي مفيش H2O Reabsorption فبنقلل ال Hypervolemia
وبيتصلح تركيز ال Na في الSerum
satavaptan , tolvaptan and lixivaptan lead to an increased urine volume, a solute-free water excretion, and an improvement of hyponatremia in 45–82% of cases.
في كمان ال conivaptan
Short term intravenous infusion of conivaptan for one to four days in patients with end stage liver disease awaiting OLT was also effective in increasing serum sodium concentration.
ال safety لل vaptan حسب الدراسات اللي انعملت كانت
للShort term use بتتراوح من اسبوع ل شهر
اما ال long term use ف كان مصحوب بزيادة في ال mortality
When satavaptan was used long term, in addition to diuretics, despite improving both serum sodium concentration and control of ascites, a higher all-cause mortality rate, mostly associated with known complications of cirrhosis, was reported compared to standard medical treatment.
Moreover, a recent study cast doubt on the efficacy of tolvaptan in patients with cirrhosis and severe hypervolemic hyponatremia (serum sodium ≤125 mEq/L) in a real-life setting.
At present, both conivaptan and tolvaptan have been approved in the US by the FDA, while only tolvaptan in Europe has been approved by the EMA for management of severe hypervolemic hyponatremia (<125 mmol/L).
The unique indication given for tolvaptan by the EMA is SIADH, while the FDA also included heart failure and liver cirrhosis.
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