Hypovolemic Hyponatremia in Cirrhosis

According to the 2014 study, “Prevalence, Incidence, and Etiology of Hyponatremia in Elderly Patients with Fragility Fractures,” in elderly, frail, hospitalized patients, the top 6 most common causes of hyponatremia were found to be…

1.       Medications – Most commonly diuretics, particularly thiazides
2.       Dehydration – Including poor PO intake and GI losses
3.       SIADH – while in all-comers, euvolemic hyponatremia is the most common etiology of hypotonic hyponatremia, with SIADH being the most common cause within that category
4.       Glucocorticoid Deficiency
5.       Cirrhosis – a type of hypervolemic hyponatremia
6.       CHF – a type of hyervolemic hyponatremia

According to Dr. McGee’s Rational Clinical Exam Article (JAMA 2012), Is this patient hypovoelmic?, the exam findings with the strongest positive likelihood ratios for hypovolemia are..

1.       Delayed cap refill – 6.9x
2.       Sunken eyes – 3.4x
3.       Speech not clear or expressive – 3.1x
4.       Dry Axilla – 2.8x
5.       ULE/LE weakness -2.3x
6.       Dry Tongue – 2.1x
7.       Confusion – 2.1x

Delayed capillary refill is the physical exam finding with the highest positive likelihood ratio for hypovolemia.

Delayed capillary refill is the physical exam finding with the highest positive likelihood ratio for hypovolemia.

 

HYPOvolemic hyponatremia represents 10% of all hyponatremias in patients with cirrhosis.  However, volume status can be very difficult to tease out in cirrhotics.  According to the 2015 Journal of Clinical Medicine article, the top 3 clinical signs of hypovolemia in cirrhosis are...

1.       Hypotension
2.       Tachycardia
3.       Renal Failure