Skip to main content

Advertisement

Log in

Water, electrolyte, acid–base, and trace elements alterations in cirrhotic patients

  • Nephrology - Review
  • Published:
International Urology and Nephrology Aims and scope Submit manuscript

Abstract

Chronic hepatic patients, and particularly those suffering from cirrhosis, are predisposed to different sort of water, electrolyte, acid–base, and trace elements disorders due to their altered liver function, and also to their exposition to infectious, inflammatory, oncologic, and pharmacologic variables whose combination undermines their homeostatic capability. Hyponatremia, hypokalemia, hyperkalemia, hypocalcemia, metabolic acidosis, respiratory, and metabolic alkalosis are the main internal milieu alterations in this group.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Gabow PA, Moore S, Schrier RW (1979) Spironolactone-induced hyperchloremic acidosis in cirrhosis. Ann Intern Med 90(3):338–340

    Article  CAS  PubMed  Google Scholar 

  2. Agarwal R, Knochel J (1996) Fluid and electrolyte disorders associated with alcoholism and liver disease. In: Kokko J, Tannen R (eds) Fluids and electrolytes. Saunders, Philadelphia, pp 449–485

    Google Scholar 

  3. Papper S (1976) Fluid and electrolyte disturbances in cirrhosis. Am J Med Sci 272(1):53–56

    Article  CAS  PubMed  Google Scholar 

  4. Guevara M, Cárdenas A, Uríz J, Gines P (2005) Prognosis of patients with cirrhosis and ascites. In: Gines P, Arroyo V, Rodés J, Schrier RW (eds) Ascites and renal dysfunction in liver diseases. Pathogenesis, diagnosis and treatment. Blackwell, Oxford, pp 260–270

    Chapter  Google Scholar 

  5. Biggins SW, Kim WR, Terrault NA, Saab S, Balan V, Schiano T, Benson J, Therneau T, Kremers W, Wiesner R, Kamath P, Klintmalm G (2006) Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 130(6):1652–1660

    Article  PubMed  Google Scholar 

  6. Heuman DM, Abou-Assi SG, Habib A, Williams LM, Stravitz RT, Sanyal AJ, Fisher RA, Mihas AA (2004) Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology 40(4):802–810

    Article  PubMed  Google Scholar 

  7. Vaa BE, Asrani SK, Dunn W, Kamath PS, Shah VH (2011) Influence of serum sodium on MELD-based survival prediction in alcoholic hepatitis. Mayo Clin Proc 86(1):37–42

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Chiandussi L, Bartoli E, Arras S (1978) Reabsorption of sodium in the proximal renal tubule in cirrhosis of the liver. Gut 19(6):497–503

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Gentilini P, Laffi G, La Villa G, Raggi VC (1999) Pathogenetic factors and clinical elements in ascites and hepatorenal syndrome during liver cirrhosis. Ann Ital Med Int 14(4):264–284

    CAS  PubMed  Google Scholar 

  10. Peña JC (1995) Renal and extra-renal mechanisms of sodium and water retention in cirrhosis with ascites. Rev Investig Clin 47(1):63–79

    Google Scholar 

  11. Caregaro L, Angeli P, Merlo A, Menon F, Rondana M, Merkel C, Gatta A (1987) Tubular handling of sodium and phosphate in non-ascitic liver cirrhosis. Scand J Clin Lab Investig 47(3):247–251

    Article  CAS  Google Scholar 

  12. Kashani A, Landaverde C, Medici V, Rossaro L (2008) Fluid retention in cirrhosis: pathophysiology and management. QJM 101(2):71–85

    Article  CAS  PubMed  Google Scholar 

  13. Knauf H, Wenk E, Schölmerich J, Goerg KJ, Gerok W, Leser HG, Mutschler E (1990) Prediction of diuretic mobilization of cirrhotic ascites by pretreatment fractional sodium excretion. Klin Wochenschr 68(11):545–551

    Article  CAS  PubMed  Google Scholar 

  14. Knauf H, Mutschler E (1994) Liver cirrhosis with ascites: pathogenesis of resistance to diuretics and long-term efficacy and safety of torasemide. Cardiology 84(Suppl 2):87–98

    Article  PubMed  Google Scholar 

  15. Marchi S, Cecchin E (1988) Acute metabolic alkalosis with hypokalemia and azotemia following massive upper gastrointestinal hemorrhage in a 54-year-old alcoholic man with cirrhosis. Am J Nephrol 8:433–434

    Article  PubMed  Google Scholar 

  16. Schrier RW (2011) Use of diuretics in heart failure and cirrhosis. Semin Nephrol 31(6):503–512

    Article  CAS  PubMed  Google Scholar 

  17. Torre Delgadillo A (2005) Refractory ascites and dilutional hyponatremia: current treatment and new aquaretics. Rev Gastroenterol Mex 70(3):299–310

    PubMed  Google Scholar 

  18. Lizaola B, Bonder A, Tapper EB, Mendez-Bocanegra A (2016) Cardenas A The changing role of sodium management in cirrhosis. Curr Treat Options Gastroenterol 14(2):274–284

    Article  PubMed  Google Scholar 

  19. Maiwall R, Kumar S, Sharma MK, Wani Z, Ozukum M, Sarin SK (2016) Prevalence and prognostic significance of hyperkalemia in hospitalized patients with cirrhosis. J Gastroenterol Hepatol 31(5):988–994

    Article  CAS  PubMed  Google Scholar 

  20. John S, Thuluvath PJ (2015) Hyponatremia in cirrhosis: pathophysiology and management. World J Gastroenterol 21(11):3197–3205

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Arroyo V, Jiménez W (2000) Complications of cirrhosis. II. Renal and circulatory dysfunction. Lights and shadows in an important clinical problem. J Hepatol 32(1 Suppl):157–170

    Article  CAS  PubMed  Google Scholar 

  22. Liamis G, Filippatos TD, Liontos A, Elisaf MS (2016) Hyponatremia in patients with liver diseases: not just a cirrhosis-induced hemodynamic compromise. Hepatol Int 10(5):762–772

    Article  CAS  PubMed  Google Scholar 

  23. Goh KP (2016) Management of hyponatremia. Am J Med Sci 352(4):385–390

    Article  Google Scholar 

  24. Iwasa M, Sugimoto R, Mifuji-Moroka R, Hara N, Yoshikawa K, Tanaka H, Eguchi A, Yamamoto N, Sugimoto K, Kobayashi Y, Hasegawa H, Takei Y (2016) Factors contributing to the development of overt encephalopathy in liver cirrhosis patients. Metab Brain Dis 31(5):1151–1156

    Article  PubMed  Google Scholar 

  25. Córdoba J, García-Martinez R, Simón-Talero M (2010) Hyponatremic and hepatic encephalopathies: similarities, differences and coexistence. Metab Brain Dis 25(1):73–80

    Article  PubMed  Google Scholar 

  26. Astrup J, Prytz H, Thomsen AC, Westrup M (1980) Red cell sodium and potassium contents in liver cirrhosis. Gastroenterology 78(3):530–534

    CAS  PubMed  Google Scholar 

  27. Kalambokis G, Milionis H, Elisaf M, Tsianos EV (2005) Terlipressin avoids hemodialysis in the treatment of refractory hyperkalemia associated with renal dysfunction in cirrhosis. Am J Med 118(9):1051–1052

    Article  PubMed  Google Scholar 

  28. Pose E, Solà E, Piano S, Gola E, Graupera I, Guevara M, Cárdenas A, Angeli P, Ginès P (2016) Limited Efficacy of tolvaptan in patients with cirrhosis and severe hyponatremia. Real life experience. Am J Med S0002–9343(16):31017–31018

    Google Scholar 

  29. Fukui H (2015) Do vasopressin V2 receptor antagonists benefit cirrhotics with refractory ascites? World J Gastroenterol 21(41):11584–11596

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Liamis GL, Milionis HJ, Rizos EC, Siamopoulos KC, Elisaf MS (2000) Mechanisms of hyponatraemia in alcohol patients. Alcohol Alcohol 35(6):612–616

    Article  CAS  PubMed  Google Scholar 

  31. Imbriano LJ, Mattana J, Drakakis J, Maesaka JK (2016) identifying different causes of hyponatremia with fractional excretion of uric acid. Am J Med Sci 352(4):385–390

    Article  PubMed  Google Scholar 

  32. Decaux G, Soupart A, Cauchie P, Delwiche F (1988) Potassium homeostasis in liver cirrhosis. Arch Intern Med 148(3):547–548

    Article  CAS  PubMed  Google Scholar 

  33. Dillingham M, Anderson R (1991) Water, electrolytes, and acid base disturbances in hepatic disease. In: Maxwell M, Kleeman C, Narins R (eds) Clinical disorders of fluid and electrolyte. Panamericana, Buenos Aires, pp 763–777

    Google Scholar 

  34. Stéphan F, Paillard F (1998) Terlipressin-exacerbated hypokalaemia. Lancet 351(9111):1249–1250

    Article  PubMed  Google Scholar 

  35. Artz SA, Paes IC, Faloon WW (1966) Hypokalemia-induced hepatic coma in cirrhosis. Occurrence despite neomycin therapy. Gastroenterology 51(6):1046–1053

    CAS  PubMed  Google Scholar 

  36. Tannen R (1996) Potassium disorders. In: Kokko J, Tannen R (eds) Fluids and electrolytes. Saunders, Philadelphia, pp 111–199

    Google Scholar 

  37. Musso CG, Casciato P, Gaite L, Vilas, Navarro M, Martinez B, Rivera H, Luxardo R, Algranati L, Gadano A (2011) Assessment of the tubular handling of potassium in cirrhotic patients treated with a combination of furosemide + spironolactone. Electron J Biomed 3:39–43

    Google Scholar 

  38. Rivero Fernández M, Moreira Vicente V, Ledo Rodríguez A, del Árbol Ruiz, Olmos L (2007) Severe hyperpotasemia in a cirrhotic patient in relation with ginger consume. Med Clin (Barc) 129(10):397–399

    Article  Google Scholar 

  39. Wallerstedt S, Simrén M, Wahlin S, Lööf L, Hultcrantz R, Sjöberg K, Gertzén HS, Prytz H, Almer S, Odén A (2013) Moderate hyperkalemia in hospitalized patients with cirrhotic ascites indicates a poor prognosis. Scand Gastroenterol 48(3):358–365

    Article  CAS  Google Scholar 

  40. Sheen SS, Park RW, Yoon D, Shin GT, Kim H, Park IW (2015) The Model for end-stage liver disease score is potentially a useful predictor of hyperkalemia occurrence among hospitalized angiotensin receptor blocker users. J Clin Pharm Ther 40(1):48–54

    Article  CAS  PubMed  Google Scholar 

  41. Radó JP, Marosi J, Takó J, Dévényi I (1968) Hyperkalemic intermittent paralysis associated with spironolactone in a patient with cardiac cirrhosis. Am Heart J 76(3):393–398

    Article  PubMed  Google Scholar 

  42. Abbas Z, Mumtaz K, Salam A, Jafri W (2003) Factors predicting hyperkalemia in patients with cirrhosis receiving spironolactone. J Coll Physicians Surg Pak 13(7):382–384

    PubMed  Google Scholar 

  43. Bruno CM (2016) Acid-base disturbance in liver cirrhosis. Eur J Gastroenterol Hepatol 28(3):363

    Article  PubMed  Google Scholar 

  44. Better OS (1982) Acquired distal renal tubular acidosis in man. Klin Wochenschr 60:1215–1217

    Article  CAS  PubMed  Google Scholar 

  45. Shear L, Bonkowsky HL, Gabuzda GJ (1969) Renal tubular acidosis in cirrhosis. A determinant of susceptibility to recurrent hepatic precoma. N Engl J Med 280(1):1–7

    Article  CAS  PubMed  Google Scholar 

  46. Häussinger D, Steeb R, Gerok W (1990) Ammonium and bicarbonate homeostasis in chronic liver disease. Klin Wochenschr 68(3):175–182

    Article  PubMed  Google Scholar 

  47. Wills MR, Savory J (1984) Vitamin D metabolism and chronic liver disease. Ann Clin Lab Sci 14(3):189–197

    CAS  PubMed  Google Scholar 

  48. Kefalas CH, Murray NG, Aguanno JJ, Dockery WD, Weinstein JS, Anderson K, Klintmalm GB (2004) Pseudohypocalcemia after magnetic resonance imaging with gadolinium in patients with cirrhosis. Liver Transpl 10(1):136–140

    Article  PubMed  Google Scholar 

  49. Akinci B, Comlekci A, Tankurt E (2009) Hypercalcemia of primary hyperparathyroidism was treated by cinacalcet in a patient with liver cirrhosis. Exp Clin Endocrinol Diabetes 117(3):142–145

    Article  CAS  PubMed  Google Scholar 

  50. Chung HS, Cho SJ, Park CS (2012) Effects of liver function on ionized hypocalcaemia following rapid blood transfusion. J Int Med Res 40(2):572–582

    Article  CAS  PubMed  Google Scholar 

  51. Jespersen B, Fogh-Andersen N, Brock A (1994) Parathyroid hormone in blood pressure and volume homeostasis in healthy subjects, hyperparathyroidism, liver cirrhosis and glomerulonephritis. A possible interaction with angiotensin II and atrial natriuretic peptide. Scand J Clin Lab Investig 54(7):531–541

    Article  CAS  Google Scholar 

  52. Koivisto M, Valta P, Höckerstedt K, Lindgren L (2002) Magnesium depletion in chronic terminal liver cirrhosis. Clin Transpl 16(5):325–328

    Article  Google Scholar 

  53. de la Coba Ortiz C, Argüelles Arias F, Martín de Argila de Prados C, Júdez Gutiérrez J, Linares Rodríguez A, Ortega Alonso A, Rodríguez de Santiago E, Rodríguez-Téllez M, Vera Mendoza MI, Aguilera Castro L, Álvarez Sánchez A, Andrade Bellido RJ, Bao Pérez F, Castro Fernández M, Giganto Tomé F (2016) Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva. Rev Esp Enferm Dig 108(4):207–224

  54. Musso CG (2009) Magnesium metabolism in health and disease. Int Urol Nephrol 41(2):357–362

    Article  CAS  PubMed  Google Scholar 

  55. De Marchi S, Cecchin E, Basile A, Bertotti A, Nardini R, Bartoli E (1993) Renal tubular dysfunction in chronic alcohol abuse–effects of abstinence. N Engl J Med 329(26):1927–1934

    Article  PubMed  Google Scholar 

  56. Aagaard NK, Andersen H, Vilstrup H, Clausen T, Jakobsen J, Dørup I (2002) Muscle strength, Na, K-pumps, magnesium and potassium in patients with alcoholic liver cirrhosis—relation to spironolactone. J Intern Med 252(1):56–63

    Article  CAS  PubMed  Google Scholar 

  57. Nangliya V, Sharma A, Yadav D, Sunder S, Nijhawan S, Mishra S (2015) Study of trace elements in liver cirrhosis patients and their role in prognosis of disease. Biol Trace Elem Res 165(1):35–40

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

Musso CG and Juarez R collected the data and wrote the paper; Glassock RJ reviewed and edited the paper.

Corresponding author

Correspondence to Carlos G. Musso.

Ethics declarations

Conflict of interest

Authors declare no conflict of interest for this article.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Musso, C.G., Juarez, R. & Glassock, R.J. Water, electrolyte, acid–base, and trace elements alterations in cirrhotic patients. Int Urol Nephrol 50, 81–89 (2018). https://doi.org/10.1007/s11255-017-1614-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11255-017-1614-y

Keywords

Navigation