European Journal of Cardiovascular Medicine

Decompensated chronic liver disease (DCLD) refers to acute deterioration in liver function in patients with cirrhosis. DCLD can lead to a wide spectrum of complications, including but not limited to thrombocytopenia, coagulopathy, ascites, bleeding varices, hepatic encephalopathy, hepato-renal syndrome, hyponatremia, anasarca, and jaundice ^1,2 and such patients typically have complex medical needs and are at high risk of hospital death. It is therefore vital that these patients receive appropriate investigations and management as early as possible in their patient journey³.

As liver cirrhosis progresses, hyponatremia becomes more prevalent and leads to severe complications⁴. Hyponatremia has also been linked to a 55% increase in the risk of death for patients with DCLD and places a major burden on health resources ⁵.The maintenance of homeostasis is crucial for the normal cellular physiology. An aberration in the management of the overall water content in the body can result in atypical sodium concentrations. The typical range for serum sodium levels is 135-145 mEq/L. Decompensated chronic liver disease (DCLD) is linked to an imbalance in water regulation, resulting in abnormalities in sodium levels known as dysnatremias^6,7. Hyponatremia is characterized by a sodium concentration below 135 mEq/L. Hyponatremia happens when water and sodium are imbalanced, with an excess of water relative to sodium which is the predominant electrolyte abnormality observed in individuals who are hospitalized, particularly those with DCLD^8,9.

 Dilutional hyponatremia occurs when there is a disruption in the control of total body water, resulting in reduced elimination of solute-free water. This leads to a failure to balance the amount of water consumed with the amount of urine produced. Hypernatremia is characterized by a sodium concentration above 145 mEq/L and is a very rare condition in individuals with DCLD. It is caused by the use of osmotic diuretic medications and upper gastrointestinal (UGI) hemorrhage. If it is present, it is linked to higher death rates¹⁰.Recent studies have indicated that decreased sodium levels in the blood are linked to higher rates of complications and death, resulting in the inclusion of serum sodium levels in the MELD score^11,12. Hypernatremia, when it occurs, is also linked to higher mortality rates.

Decompensated chronic liver disease (DCLD) refers to acute deterioration in liver function in patients with cirrhosis. DCLD can lead to a wide spectrum of complications, including but not limited to thrombocytopenia, coagulopathy, ascites, bleeding varices, hepatic encephalopathy, hepato-renal syndrome, hyponatremia, anasarca, and jaundice ^1,2 and such patients typically have complex medical needs and are at high risk of hospital death. It is therefore vital that these patients receive appropriate investigations and management as early as possible in their patient journey³.

As liver cirrhosis progresses, hyponatremia becomes more prevalent and leads to severe complications⁴. Hyponatremia has also been linked to a 55% increase in the risk of death for patients with DCLD and places a major burden on health resources ⁵.The maintenance of homeostasis is crucial for the normal cellular physiology. An aberration in the management of the overall water content in the body can result in atypical sodium concentrations. The typical range for serum sodium levels is 135-145 mEq/L. Decompensated chronic liver disease (DCLD) is linked to an imbalance in water regulation, resulting in abnormalities in sodium levels known as dysnatremias^6,7. Hyponatremia is characterized by a sodium concentration below 135 mEq/L. Hyponatremia happens when water and sodium are imbalanced, with an excess of water relative to sodium which is the predominant electrolyte abnormality observed in individuals who are hospitalized, particularly those with DCLD^8,9.

 Dilutional hyponatremia occurs when there is a disruption in the control of total body water, resulting in reduced elimination of solute-free water. This leads to a failure to balance the amount of water consumed with the amount of urine produced. Hypernatremia is characterized by a sodium concentration above 145 mEq/L and is a very rare condition in individuals with DCLD. It is caused by the use of osmotic diuretic medications and upper gastrointestinal (UGI) hemorrhage. If it is present, it is linked to higher death rates¹⁰.Recent studies have indicated that decreased sodium levels in the blood are linked to higher rates of complications and death, resulting in the inclusion of serum sodium levels in the MELD score^11,12. Hypernatremia, when it occurs, is also linked to higher mortality rates.

Table 1: Age & Sex wise distribution of Study Subjects according to Serum Sodium levels

Mean ± SD = 55.99 ± 10.13 = 49 - 66, P < 0.001

It was observed that, the burden of the disease was more between 50-70 years of age (53%) with the Mean age 56 years. Also, it was noticed that, the morbidity was higher among males (98%)   when compared to females (2%) significantly. And also regarding distribution of Serum Sodium levels it was observed that, about 40% of study subject’s Serum Sodium levels lies between 131 -135 mEq/l followed by 32% lies ≥ 136 mEq/l and 28% lies ≤ 130 mEq/l  respectively with over all Hyponatremia accounted was 68%  with the Mean ± SD = 137.7 ± 1.72 in this study.

Table 2: Distribution of study variables in association with Serum Sodium levels

Related to distribution of the risk factors in accordance with Serum Sodium levels, Alcohol accounted for 93% followed by HBV 10% and HCV 3% as observed. And MELD score with the Mean ± SD = 15.56 ± 7.28 was highly  significant among the hyponatremia patients of Serum Sodium levels ≤ 130 mEq/l when compared to patients who had normal Serum Sodium levels and there was no significant Child-pugh score  observed and in addition to this, about 74% of  study group belonged to Child-pugh class” B” in this study.

Table 3: Distribution of Complications in relation with Serum Sodium levels

With regard to distribution of Complications in accordance with Serum Sodium levels , All the patients were developed Ascites (100%) followed by 89% were developed Portal Hypertension, 22% Hepatic Encephalopathy, , 16% Coagulopathy, 14% GI bleeding 13% Hepatorenal Syndrome and 10% SBP respectively.

Figure 2: Distribution of Complications in accordance with Serum Sodium levels

Table 4: Distribution of Mortality rate in relation with Serum Sodium levels

In this study it was observed that, higher mortality (87%) was associated with Serum Sodium levels ≤ 130 mEq/l , followed by 13.33% among Serum Sodium levels between 131-135 mEq/l and totally 15% of mortality rate was observed among all the study subjects.

Figure 3: Distribution of Mortality among Study Subjects

This study investigated the demographic and clinical characteristics of patients with decompensated chronic liver disease (DCLD). The findings are as follows: The majority of patients (53%) were between 50-70 years old, with a mean age of 56 years. This finding is consistent with studies by Bhandari A et al. (13), Azum MU et al. (14), and Nareddy et al. (15). Males accounted for 98% of the study population, while females accounted for 2%. This male preponderance is consistent with studies by Nareddy et al., Jahan Sardar et al. (17), and Azumi et al. The distribution of serum sodium levels was as follows: 40% of patients had serum sodium levels between 131-135 mEq/L, 32% had levels ≥ 136 mEq/L, 28% had levels ≤ 130 mEq/L. The mean serum sodium level was 137.7 ± 1.72 mEq/L. Hyponatremia (serum sodium level < 135 mEq/L) was observed in 68% of patients, which is consistent with studies by Khyalappa R et al. (18) and Devados AD et al. (19).

The majority of patients (93%) had alcohol-related DCLD, followed by HBV (10%) and HCV (3%). These findings are consistent with studies by VN Shetty et al. (22). The MELD score was significantly higher in patients with hyponatremia (serum sodium level ≤ 130 mEq/L), which is consistent with studies by Chaudary RD et al. (23) and Ruf AE et al. (24). The most common complications were: Ascites (100%), Portal hypertension (89%), Hepatic encephalopathy (22%), Coagulopathy (16%)GI bleeding (14%), Hepatorenal syndrome (13%) and SBP (10%) respectively.

The overall mortality rate was 15%, with higher mortality rates observed in patients with serum sodium levels ≤ 130 mEq/L (87%) and between 131-135 mEq/L (13.33%). These findings are consistent with studies by Philomena James et al., Kumar VS et al. (26), and VN Shetty et al.

This study highlights the importance of monitoring serum sodium levels and managing complications in patients with DCLD. The findings suggest that hyponatremia is a significant predictor of mortality in these patients, and that early recognition and management of electrolyte imbalances can improve outcomes.

LIMITATIONS

The study was hospital-based and conducted on a small group of patients, with no follow-up. This limitation may affect the generalizability and long-term implications of the findings. Larger studies with extended follow-up periods could provide more comprehensive insights into the disease's progression and outcomes

This study highlights the importance of targeting interventions and preventive strategies towards specific age groups and males, given the proportional distribution of decompensated chronic liver disease (DCLD) with advancing age and the observed male preponderance. Implementing health education-based intensive awareness programs involving healthcare workers, local NGOs, and electronic and print media can help control the incidence and prevalence of the disease.

Low serum sodium levels are strongly associated with the severity of DCLD and complications such as hepatic encephalopathy, portal hypertension, GI bleeding, coagulopathy, ascites, and hepatorenal syndrome. Importance of screening and monitoring*: Regular monitoring of serum sodium levels, along with MELD scores, can facilitate better management of chronic liver disease and enable timely identification and effective management of disease progression. Early identification and management of disease progression can decrease morbidity and prolong survival in patients with hepatic cirrhosis. Implementing targeted interventions and preventive strategies towards specific age groups and males can help control the incidence and prevalence of DCLD. Health education-based intensive awareness programs can play a crucial role in preventing and managing DCLD. A multidisciplinary approach involving healthcare workers, local NGOs, and electronic and print media can help raise awareness and promote early detection and management of DCLD.

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