July’s Article of the Month, with commentary from Dr. Cale Kassel, is a narrative review on hyponatremia in liver transplantation — one of the most common electrolyte challenges anesthesiologists face perioperatively, and the source of the rare but devastating osmotic demyelination syndrome (ODS). The review consolidates the evidence on outcomes, walks through pre-, intra-, and postoperative management strategies, and offers practical guidance — including a reference table for diluting standard fluids and blood products with D5W to control sodium delivery.
Key Findings
- Outcomes data are mixed: Early studies suggested increased 90-day mortality with hyponatremia; more recent data show no difference, though ICU length of stay and morbidity remain elevated. One 40,000-patient study showed increased mortality with serum Na < 120 mmol/L
- ODS incidence after LT: 0.8–1.4% (vs. 0.6% in the general population), with substantially higher associated mortality (77% in LT vs. 45% in non-LT patients)
- ODS prevention: Avoid raising serum sodium more than 8 mmol/L in 24 hours; degree of correction correlates with baseline hyponatremia, intraoperative blood loss, and IV fluid volume
- Preoperative levers: Hold loop diuretics, free-water restriction, 25% albumin, and nephrology consultation can carefully raise sNa before transplant
- Intraoperative strategies: Viscoelastic testing to limit FFP (Na 172 mmol/L), factor concentrates instead of plasma/cryo, and modified CRRT dialysate (sterile water added to reduce Na concentration)
- Practical table: The authors provide a reference for D5W volumes needed to reduce standard fluids to 125 mmol/L — e.g., 232 mL D5W added to 1 L normal saline
