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Hyponatremia in Cirrhosis

John Laurenzano


  • Most commonly is hypervolemic hyponatremia, driven by release of ADH from decreased effective arterial blood volume (EABV) in the setting of portal hypertension

  • Hyponatremia in cirrhosis is a marker of advanced disease and is associated with higher rates of SBP, HE, HRS, and mortality.


  • Standard evaluation of hyponatremia, including Uosm, Sosm, UNa to rule out competing processes (e.g. beer potomania)


  • Discontinue anti-hypertensives (including beta blockers) in patients with ascites and hyponatremia. Hold diuretics when Na <125

  • Fluid restriction is recommended only in patients with Na <125. Restriction is generally effective at 1-1.5L and must be less than daily urine output to increase free water excretion

  • Replete potassium to 4.0, as potassium is as osmotically active and results in shifts in extra and intracellular fluids which lead to a net increase in serum sodium.

  • 25% albumin infusion (1g/kg split into BID dosing), has been shown to increase serum sodium and have higher rates of hyponatremia resolution at 30 days

  • Other treatment considerations include vasopressors, vaptans, urea tabs

  • Salt tabs should not be used to raise serum Na due to worsening hypervolemia

  • Nephrology should be consulted if not improved after 48 hours

Last update: 2022-06-21 11:02:58