This study evaluated the frequency and impact of hyponatremia (sodium levels below 130 mEq/L) in 217 patients with liver cirrhosis and ascites. Hyponatremia was found in 26.7% of patients and was associated with more severe liver disease and ascites. Patients with hyponatremia also experienced more frequent hepatic encephalopathy and cirrhosis complications like hepatorenal syndrome and spontaneous bacterial peritonitis during their hospital stay compared to patients with normal sodium levels. The study concluded that hyponatremia is common in cirrhotic patients and negatively influences the development of cirrhosis complications.
By Dr. Usama Ragab, Zagazig Faculty of Medicine
PSC incidence ranges from 0.5 to 1.25 cases/100 000.
The prevalence of the disease ranges between six and 20 cases/100 000.
Men are more likely to be affected (70%).
Prevalence of PSC may be increased in first degree relatives of PSC patients
outh Africa has one of the highest incidences of human immunodeficiency virus (HIV) infection in Africa. The rollout of antiretroviral therapy (ART) in South Africa has been tremendously successful in extending the lives of HIV-infected persons. Consequently, more patients who would have died before the availability of ART are now receiving a diagnosis of HIV-associated nephropathy.1
The rates of disease progression and death in the population of HIV-positive patients with chronic kidney disease can be modified by ART, which reduces the risk of advanced chronic kidney disease among patients with HIV-associated nephropathy by approximately 60%.2,3 It has been estimated that the prevalence of chronic kidney disease among HIV-infected patients receiving treatment is between 8% and 22%4-7; among untreated patients, it is estimated to be between 20% and 27%.8,9 Confronted with a high burden of HIV disease and limited resources, South Africa faces considerable challenges in providing renal-replacement therapy for the large numbers of HIV-infected persons in whom chronic kidney disease will develop during their lifetime.
By Dr. Usama Ragab, Zagazig Faculty of Medicine
PSC incidence ranges from 0.5 to 1.25 cases/100 000.
The prevalence of the disease ranges between six and 20 cases/100 000.
Men are more likely to be affected (70%).
Prevalence of PSC may be increased in first degree relatives of PSC patients
outh Africa has one of the highest incidences of human immunodeficiency virus (HIV) infection in Africa. The rollout of antiretroviral therapy (ART) in South Africa has been tremendously successful in extending the lives of HIV-infected persons. Consequently, more patients who would have died before the availability of ART are now receiving a diagnosis of HIV-associated nephropathy.1
The rates of disease progression and death in the population of HIV-positive patients with chronic kidney disease can be modified by ART, which reduces the risk of advanced chronic kidney disease among patients with HIV-associated nephropathy by approximately 60%.2,3 It has been estimated that the prevalence of chronic kidney disease among HIV-infected patients receiving treatment is between 8% and 22%4-7; among untreated patients, it is estimated to be between 20% and 27%.8,9 Confronted with a high burden of HIV disease and limited resources, South Africa faces considerable challenges in providing renal-replacement therapy for the large numbers of HIV-infected persons in whom chronic kidney disease will develop during their lifetime.
Study of Hyponatremia and its Outcome in Cirrhosis of Liversemualkaira
1.1. Background: Hyponatremia in cirrhosis is currently defined
as a serum sodium level of less than 130 meq/L. Recent studies
have reported that lower serum sodium levels are associated with
increased complications and mortality leading to incorporation of
sodium in the Model For End Stage Liver Disease. Therefore, we
undertook this study in our tertiary hospital to study serum sodium
levels in patients admitted with cirrhosis of liver and its outcome.
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Frequency of hyponatraemia and its influence on liver cirrhosis related complications
1. Original Article
Frequency of hyponatraemia and its influence on liver
cirrhosis-related complications
Samiullah Shaikh, Gomo mal, Shaikh Khalid, Ghulam Hussain Baloch, Yousfani Akbar
Department of Medicine, Liaquat University of Medical & Health Sciences, Jamshoro, Hyderabad.
Abstract
Objective: To evaluate the frequency, clinical associations and prognostic impact of hyponatraemia on cirrhosis
related complications in patients with cirrhosis of liver.
Methods: In this case control study 217 cirrhotic patients consecutively admitted to our department from
September 2006 to November 2007were studied. Serum sodium levels were determined in all patients admitted.
The cutoff level of 130 meq/l was chosen because it is widely accepted to define hyponatraemia in patients with
cirrhosis while the level of 135 meq/L is the lower normal value. Patients were grouped on the basis of serum
sodium concentration into (1) serum sodium <130 meq/L (Group1) (2) serum sodium between 131 - 135 meq /l
(Group 2), and (3) serum sodium >135 meq /l (Group3). P values of less than 0.05 were considered as
significant. The patients with hyponatraemia Group1(<130 meq/l) and group 2 (131-135meq/l) were compared
with group 3 (>135 meq/l) for the severity of liver disease, degree of ascites and other cirrhosis related
complications such as hepatorenal syndrome, spontaneous bacterial peritonitis and hepatic encephalopathy.
Results: This case control study constituted 217 consecutive cirrhotic patients of which 141(65%) were male and
76/217 (35%) were female. Hyponatraemia (sodium <130meq/l) was found in 58 / 217 (26.7%) patients and
54/217 (24.9%) had serum sodium from 131-135meq/l whereas 105/ 217 (48.4%) patients had serum sodium
>135. Out of 58 patients with hyponatraemia, 48 were in child -Pugh C class (p=0.001). Patients with serum
sodium <130meq/l had more severe ascites (p= 0.001) requiring frequent paracentesis and higher dosages of
diuretics. Hepatic encephalopathy was more frequent in patients with serum sodium < 130 meq/l (p= 0.001). The
cirrhosis related complications were also significantly increased in patients with mild hyponatraemia (131-135
meq/l) than in patients with normal serum sodium (>135 meq/l).
Conclusion: Hyponatraemia is frequent in cirrhotic patients. It is seldom spontaneous and has a negative
influence on cirrhosis related complications (JPMA 60:116; 2010).
Introduction cirrhotic patients being treated for an episode of ascites is
Hyponatraemia is frequent in cirrhosis with ascites. In 35%, and it is one of the most important prognostic factors in
a series by Arroyo et. al.1 of their 50 consecutive cirrhotic these patients.3 Patients with hyponatraemia have a poor
patients in a year, 20 were found to have plasma Na below 130 survival compared with that of patients without
meq/l. The hyponatraemia is thought to be due to a higher rate hyponatraemia.4 In contrast with the large amount of
of renal retention of water in relation to sodium due to a information that has been accumulated on the value of serum
reduction in solute-free water clearance. The consequent sodium in the prediction of prognosis, little is known
inability to adjust the amount of water excreted in the urine to regarding the clinical significance of the presence of
the amount of water ingested leads to dilutional hyponatraemia, particularly the relationship between serum
hyponatraemia.2 The incidence of dilutional hyponatraemia in sodium levels and characteristics of ascites and development
116 J Pak Med Assoc
2. of complications of cirrhosis. Therefore, the aim of the present prevented) because of complications induced by diuretics that
study was to assess the frequency of low serum sodium levels preclude the administration of effective doses.
and to compare hyponatremic cirrhotic patients with normal All patients were admitted for four week duration.
sodium cirrhotic patients so as to assess the severity of liver During that period patients were assessed for the occurrence
disease, characteristics of ascites and occurrence of of complications of cirrhosis other than ascites, such as
complications of cirrhosis such as hepatorenal syndrome spontaneous bacterial peritonitis, hepatic encephalopathy, and
(HRS) and spontaneous bacterial peritonitis (SBP) during hepatorenal syndrome.
hospital stay of the cirrhotic patients. The presence of portal-systemic encephalopathy (PSE)
Methods was diagnosed on the basis of speech, personality, intellectual
disorders, and asterixis and graded as absent, mild or severe.7
This case control study included 217 consecutive HCC was diagnosed by ultrasonography (US) or computed
patients with cirrhosis of liver having ascites admitted in tomography (CT) imaging and high values of serum α-
medical department of Liaquat university hospital fetoprotein (>200 ng/ml) or by biopsy.
Jamshoro/Hyderabad from September 2006 to November
2007. The recording of consecutive patients was designed to Patients were diagnosed to have hepatorenal syndrome
avoid any bias due to selection of patients. Patients were according to International Ascites Club's definition of hepato-
included in the study according to the following criteria: (1) renal syndrome.8
diagnosis of cirrhosis confirmed clinical, biochemical, and 1. Chronic liver disease with advanced hepatic failure
ultrasonographic findings; and (2) presence of ascites and portal hypertension.
determined via paracentesis or ultrasonography. The exclusion 2. Low glomerular filtration rate, as indicated by
criteria were patients with hepatocellular carcinoma (HCC) serum creatinine of more than 1.5 mg/ dl or 24-hour creatinine
and patients with exudative ascites. clearance less than 40 ml /min.
The data of the patients was collected in a well 3. Absence of shock, ongoing bacterial infection, and
designed proforma. The patients' demographics and the status current or recent treatment with nephrotoxic drugs. Absence of
of the patients at the time of inclusion (inpatient or outpatient) gastrointestinal fluid losses (repeated vomiting or intense
as well as severity of cirrhosis was assessed according to diarrhoea) or renal fluid losses (weight loss more than 500 g per
Child-Pugh score.5 A total score from 5-6, 7-9 and 10-15 was day for several days in patients with ascites without peripheral
classified as class A, B and C respectively. The patients were oedema or 1,000 g per day in patients with peripheral oedema).
assessed for ascites and were graded according to
International AscitesClub.1,6 4. No sustained improvement in renal function
(decrease in serum creatinine to 1.5 mg /dl or less, or increase
1. Uncomplicated ascites: Ascites that is not infected in creatinine clearance to 40 ml/ minor more) after diuretic
and is not associated to hepatorenal syndrome. It is divided withdrawal and expansion of plasma volume with 1.5 litres of
into 3 groups: isotonic saline
a. Grade 1 (mild): Only detected on ultrasound 5. Proteinuria less than 500 mg/dl and no
examination. ultrasonographic evidence of obstructive uropathy or
b. Grade 2 (moderate): Manifested by symmetric parenchymal renal disease.
distention of the abdomen. Patients with hepatorenal syndrome were given
c. Grade 3 (severe): Gross ascites with marked Terlipressin and albumin until the reversal of the HRS
abdominal distention. (decrease of serum creatinine below 1.5 mg/dl).9
2. Refractory ascites: It was defined in 1996 by the SBP is the infection of the ascitic fluid that occurs in
International Ascites Club as ascites that cannot be mobilized the absence of a visceral perforation and in the absence of an
or the early recurrence of which (i.e., after therapeutic intra abdominal inflammatory focus such as abscess, acute
paracentesis) cannot be satisfactorily prevented by medical pancreatitis or cholecystitis.10 For SBP diagnosis, the number
therapy. Two subgroups were identified: of polymorphonuclear leucocytes (PMN) from the ascitic
a. Diuretic-resistant ascites: Ascites that cannot be fluid obtained by paracentesis, must exceed 250 cells/mm and
mobilized or the early recurrence of which cannot be or positive bacteriological cultures showing single organism.
prevented because of lack of response to dietary sodium All patients with bacterial infection were submitted to
restriction and intensive diuretic treatment. treatment with cefotaxime or other antibiotics according to the
b. Diuretic-intractable ascites: Ascites that cannot be results of cultures.
removed (or the early recurrence of which cannot be The patients on diuretic treatment were then classified
Vol. 60, No. 2, February 2010 117
3. according to the number of diuretics that they were taking. Table-1: Baseline Characteristics of patients with cirrhosis of liver
The following information was then collected in patients on admitted at Liaquat University Hospital, Jamshoro, Hyderabad.
current diuretic treatment: dose of spironolactone (mg/d), Variables Number of patients Frequency Percent
furosemide (mg/d), and other diuretic agents. The following
information on therapeutic paracentesis was collected: Sex Male 217 141 65
repeated use of paracentesis, time interval between the last Female 76 35
Ascites - -
two paracentesis (weeks), and volume of ascites removed at Grade2(moderate) 217 82 37.8
the last paracentesis (in liters).10 Grade3(severe) 116 53.5
Refractory ascites 19 8.7
During hospital stay the dietary sodium was restricted H/Diabetes Mellitus 217 -
to 50 meq per day for patients with ascites. In patients with Yes 192 88.5
mild hyponatraemia, the water intake was restricted to 750 No 25 11.5
ml/day and in those with severe hyponatraemia to 500 ml/day. Ch.Pugh grade* 217 - -
Grade-B 84 38.5
The tests carried out in the patients were serum Grade-C 133 61.5
electrolytes, serum creatinine, LFT, serum albumin, S.sodium level(meq/l) 217
prothrombin time and were added in the proforma. Serum <130 58 26.7
131-135 54 24.9
sodium was determined on admission and repeated weekly >135 105 48.4
during the course of the patient. Patients were divided into Paracentesis 217 - -
three groups according to serum sodium concentration as No paracentesis 88 40.6
follows: serum sodium <130 meql/l (Group1), serum sodium Paracentesis once 60 27.6
Paracentesis twice 30 13.8
between 131 meq/l and 135 meq/l(Group 2), and serum Paracentesis >twice 39 18
sodium >135 meq/l (Group3). Group 3 was taken as H/O Diuretics** 217 197 88.9
control.Group1( <130 meq/l) and group 2 (131-135meq/l) No H/O Diuretics 20 10.1
were compared with group3 (>135 meq/l) for the severity of Spironolactone 197 88.9
Spironolactone and furosemide 167 76.9
liver disease, degree of ascites and other cirrhosis related
complications such as hepatorenal syndrome, spontaneous *Ch.Pugh grade: Child Pugh Score. ** H/O Diuretics: History of Diuretics.
bacterial peritonitis and hepatic encephalopathy.
Table-2: Comparison of liver cirrhosis related complications
Statistics: according to serum sodium levels.
Descriptive statistics are provided as means ± 1 SD. Parameter S.Sodium S.Sodium S.Sodium
The t-test was used to compare quantitative data, and the chi- <130meq/l <131-135meq/l >135meq/l
(n=58) group1 (n=54) group2 (n=105) group3
square test was used for categorical data. All analyses were
carried out using SPSS software version 16 (SPSS, Inc, Child-Pugh Class
Chicago, B 10 17 64
C 48 35 41
P values of less than 0.05 were considered statistically P=Value 0.001 0.002 0.144
significant. To determine the sample size, we assumed a Encephalopathy
confidence level of 95%, with a power of 80%. We predicted No 43 49 98
a finding of 30% hyponatraemia in our group of cirrhotic Yes 15 06 7
P=Value 0.001 0.005 0.40 (NS)
patients, on the basis of previous data.11 Ascites 12 15 40
Results Grade2
Grade3
33
13
37
2
58
7
This case control study framed 217 consecutive Refractory 0.001 0.029 0.87(NS)
cirrhotic patients of which 141 (65%) were male and 76
(35%) female. The mean age of the patients were 46.8 ± 13 sodium < 130 meq/l, 48 were in class C Child-Pugh and 10
years. Hyponatraemia (sodium <130meq/l) was present in 58/ were in Class B (p=0.001). A more severe grade of ascites
217(26.7%) patients and 54/ 217 (24.9%) patients had serum was present in patients with low serum sodium. Grade 2
sodium from 131-135 meq/l while 105/ 217 (48.4%) patients ascites was present in 12/58, grade3 in 33/58 patients and
had serum sodium >135 meq/l. Patients with serum sodium < refractory ascites in 13/58 patients with serum sodium < 135
130 meq/l were kept in group 1, with 131-135 meq/l in group meq/l (p= 0.003) needing frequent paracentesis and higher
2 and >135 meq/l as control (group3). Table-1 shows basic dosages of diuretics. The duration of hospital stay of the
characteristics of all the patients in the study. Low serum patients was 3-5 weeks in all groups. During the hospital
sodium had significantly high Child Pugh class compared to follow up of the patient 8/ 13 patients with refractory ascites
a normal serum sodium. Among 58 patients with serum developed hepatorenal syndrome with serum sodium <130
118 J Pak Med Assoc
4. meq/l and one patient with serum sodium 130-135 meq/l. meq/l have a higher frequency of refractory ascites, lower
Spontaneous bacterial peritonitis was present in 10/58 response in terms of change in body weight, higher
patients with serum sodium < 130 meq/l ,3/54 patient with requirement of large-volume paracentesis to manage their
serum sodium 131-135 meq/l and 1/105 patient with >135 ascites, and a shorter interval between paracentesis.
meq/l. Hepatic encephalopathy was present in 26/217 Subsequent study by Bernardi et al.14 and Angeli15
(11.9%) patients, of which15/58(25.8%) patients were with showed that patients who do not respond to diuretics have
serum sodium <130meq/l (p=0.001). Table-2 shows the lower serum sodium concentration compared with patients
comparison of cirrhosis related complications according to who respond to diuretics Moreover, the results show that
serum sodium. History of diuretic therapy was present in patients with serum sodium between 131 and 135 meq/L
193/217 (88.9%).All patients were on Spironolactone 28/54 (53.7%) have signs of poor ascites response compared
ranging from 100-300mg/d and 167/217 (76.9%) patients with patients with normal serum sodium concentration
were on combination of Spironolactone and furosemide given (34/105) (32%), although to a lesser extent than patients
in a dosage of 12 to 40 mg/d. Large volume paracentesis was meeting the classical definition of hyponatraemia (serum
done once or more in 30/217 (13.7%) patients. sodium <130 meq/l). Hepatorenal syndrome was also strongly
associated with low serum sodium concentration as 8/13
Discussion patients with refractory ascites with serum sodium <130 meq/l
This case control study was done for assessing serum developed hepatorenal syndrome during follow up as
sodium concentration in patients with cirrhosis and the compared to one patient with serum sodium 130-135 meq/l
association between serum sodium levels and the occurrence and none with normal serum sodium concentration .This
of major complications of cirrhosis. The results indicate that a association may be explained by the fact that hepatorenal
large proportion of patients with cirrhosis have abnormal syndrome is frequently associated with an impaired excretion
values of serum sodium concentration. In fact, more than one of solute-free water, so that the majority of patients with
half (51.6%) of patients with cirrhosis had values of serum hepatorenal syndrome have a concomitant reduction of serum
sodium concentration below the normal range (<135 meq/l) sodium concentration.16,17 Alternatively, it has been shown
and 58/217 (26.7%) had values <130 meq/l. Low serum that hyponatraemia is a major risk factor for the development
sodium levels were more frequent in patients with severe liver of hepatorenal syndrome in patients with ascites. This
failure (59.9% (Child-Pugh class C) irrespective of age and increased risk of hepatorenal syndrome may be related to a
sex of the patients. Nevertheless, it should be pointed out that more severe circulatory dysfunction of patients with
low serum sodium levels were also found in patients with hyponatraemia compared to patients without hyponatraemia.3
moderate liver failure (Child-Pugh B). The frequency of Our data also indicate the existence of an association between
serum sodium <130 mmol/L was 26.7% in our patients in spontaneous bacterial peritonitis and low serum sodium levels
accordance with a study by Borroni G et al where in accordance with another study done by Paolo Angeli et al.15
hyponatraemia was present in 30% of cases.12 Arroyo et al. This association probably reflects the impairment in effective
also found hyponatraemia < 130 in 30% of cases.13 Moreover, circulating blood volume that occurs in patients with cirrhosis
our study showed that the occurrence of low serum sodium in the setting of spontaneous bacterial peritonitis and may lead
levels is greater than previously reported, because a further to hepatorenal syndrome in some patients, while others may
24.9% of patients had a mild reduction in serum sodium levels develop only hyponatraemia.18
(between 131 and 135 meq/l).Although, it is generally In fact, the frequency of hepatic encephalopathy was
believed that the existence of a serum sodium concentration associated with serum sodium levels in such a way that
<130 meq/l is associated with difficult-to-treat ascites, few patients with serum sodium <130 meq/l had a significantly
studies have been reported that specifically analyze the greater frequency 15/58(25.8%) of hepatic encephalopathy
relationship between serum sodium levels and responsiveness compared to patients with normal serum sodium concentration
of ascites to diuretic therapy. Arroyo et al.13 reported that the 9/92 (9.7%). Patients with serum sodium between 131 and
presence of serum sodium <130 meq/l was associated with 135 meq/l had a lower frequency of encephalopathy 06/52
lower glomerular filtration rate and solute-free clearance and (11.2%) compared to patients with serum sodium <130 meq/l,
a poorer response to diuretics compared with patients with but higher than that of patients with normal serum sodium
serum sodium>130 meq/l. Subsequent study by Bernardi et concentration. According to Paolo Angeli15 encephalopathy
al.14 showed that patients who do not respond to diuretics have was present in 38% of the patients with serum sodium <130
lower serum sodium concentration compared with patients meq/l compared with 24% of patients with serum sodium
who respond to diuretics. The results of the current study between 131 and 135 meq/l and 15% of patients had serum
46/58 (79%) confirm and extend these observations by sodium levels >135 meq/l. The relationship between hepatic
showing that patients with serum sodium concentration <130 encephalopathy and serum levels may be explained on the
Vol. 60, No. 2, February 2010 119
5. basis of more severe liver failure among patients with serum 2. Hecker R, Sherlock S. Electrolyte and circulatory changes in terminal liver
failure. Lancet 1956; 271: 1121-5.
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may be pathophysiologically linked.15 In fact, it has been Hyponatraemia in cirrhosis: from pathogenesis to treatment. Hepatology
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6. Rimola A, Garcia-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, et al.
glutamine, as a consequence of hyperammonemia, and low Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a
extracellular sodium.19-21 In experimental models of acute consensus document. International Ascites Club. J Hepatol 2000; 32: 142-53.
liver failure, the presence of hyponatraemia is associated with 7. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic
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larger brain swelling compared with normal serum sodium report of the working party at the 11th World Congresses of Gastroenterology,
concentration.22 Although the results do not make it possible Vienna, 1998. Hepatology 2002; 35: 716-21.
to prove the existence of a causal link between low serum 8. Salerno F, Gerbes A, Ginès P, Wong F, Arroyo V: Definition, diagnosis and
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14. Bernardi M, Laffi G, Salvagnini M, Azzena G, Bonato S, Marra F, et al.Efficacy
In conclusion, the results of this study indicate that low and safety of the stepped care medical treatment of ascites in live rcirrhosis: a
serum sodium levels are a common feature in patients with randomized controlled clinical trial comparing two diets withdifferent sodium
content. Liver 1993; 13: 156-62.
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greater frequency of hepatic encephalopathy compared with
17. Alessandria C, Ozdogan O, Guevara M, Restuccia T, Jimenez W, Arroyo V, et al.
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concentration <130 meq/l are those with the greatest 18. Ruiz del Arbol L, Urman J, Fernandez J, Gonzalez M, Navasa M, Monescillo A,
et al. Systemic, renal and hepatic haemodynamic derangement in cirrhotic
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Nevertheless, even patients with a mild reduction in serum 19. Haussinger D, Laubenberger J, vom Dahl S, Ernst T, Bayer S, Langer M,et
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