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Abstract: FR-PO284

Maintaining Sodium Homeostasis During Liver Transplant - A Novel Approach

Session Information

Category: Fluid and Electrolytes

  • 902 Fluid and Electrolytes: Clinical


  • Jones, Courtney, University of Cincinnati, Cincinnati, Ohio, United States
  • Thakar, Charuhas V., University of Cincinnati, Cincinnati, Ohio, United States
  • Kaur, Taranpreet, University of Cincinnati, Cincinnati, Ohio, United States

Following two cases of osmotic demyelination syndrome (ODS) in patients with near-normal serum sodium (Na) levels (134 mEq/L) at the start of orthotopic liver transplantation (OLT) at our institution, we sought a systems approach for minimizing ODS. Many patients presenting for OLT with hyponatremia have concomitant renal dysfunction necessitating intraoperative continuous renal replacement therapy (CRRT). Intraoperative CRRT using standard dialysate with a Na concentration of 140mEq/L could pose a risk due to rapid Na rise.

A multi-disciplinary approach was taken with anesthesiology, nephrology, transplant surgery, and pharmacy to create a pathway for low Na dialysate with a Na concentration of 130mEq/L for OLT patients with hyponatremia that also need intraoperative RRT. Commercially available low Na dialysate does not contain calcium (Ca), which requires frequent replacement at baseline during an OLT. Pharmacy presented the data along with a failure modes and effects analysis (FMEA) to the hospital’s drug policy committee and gained approval for compounding calcium into our commercially available low Na dialysate.

Case Description

Following implementation of our system change, a patient presented for OLT with a MELD-Na of 30, hepatorenal syndrome, acidosis, hyperkalemia, and hyponatremia (Na 124). This patient was admitted to the ICU preoperatively and initiated on CRRT with low Na dialysate compounded with Ca while waiting for the liver to arrive. Intraoperative fluid administration, transfusion, electrolytes, and acid-base status were managed in standard fashion plus the addition of low Na dialysate. At the end of the OLT, the Na had only risen to 126 over 14 hours. The low Na dialysate continued three additional days postoperatively in the ICU to allow the Na to gradually normalize. Four days after presentation, the Na was 135 and the patient was transitioned to standard dialysate and never developed ODS. He is currently off dialysis with an eGFR of 33.


ODS occurs in approximately one percent of OLT patients with associated high morbidity and mortality. The rate of Na rise is strongly correlated with the development of neurologic changes and standard dialysate can contribute to that. A multi-disciplinary system based approach achieved patient safety and allowed a platform for broader implementation to hyponatremic patients without renal dysfunction.