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Electrolyte and Acid–Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach

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Abstract

Electrolyte and acid–base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid–base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid–base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid–base spectrum. Because most electrolyte and acid–base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.

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Abbreviations

AG:

Anion gap

AKI:

Acute kidney injury

AQ2:

Aquaporin 2

AVP:

Arginine vasopressin

BP:

Blood pressure

CNI:

Calcineurin inhibitors

CNS:

Central nervous system

DRTA:

Distal renal tubular acidosis

EG:

Ethylene glycol

ENAC:

Epithelial sodium channels

ESLD:

End-stage liver disease

FFP:

Fresh frozen plasma

GFR:

Glomerular filtration rate

HE:

Hepatic encephalopathy

HRS:

Hepatorenal syndrome

NG:

Nasogastric

NH4+ :

Ammonium

NH3:

Ammonia

MELD:

Model for End-Stage Liver Disease

OLT:

Orthotopic liver transplantation

OSD:

Osmotic demyelination syndrome

PBC:

Primary biliary cirrhosis

RAAS:

Renin–angiotensin–aldosterone system

ROMK:

Renal outer medullary potassium channels

RTA:

Renal tubular acidosis

SBP:

Spontaneous bacterial peritonitis

SIAD:

Syndrome of inappropriate antidiuresis

TAL:

Thick ascending limb

TBW:

Total body water

UAG:

Urinary anion gap

VR2:

Vasopressin receptor 2

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Authors and Affiliations

  1. Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico

    José Víctor Jiménez & Eduardo Carrillo-Maravilla

  2. Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico

    Diego Luis Carrillo-Pérez & Rodrigo Rosado-Canto

  3. Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico

    Ignacio García-Juárez, Aldo Torre & David Kershenobich

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  1. José Víctor Jiménez
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Jiménez, J.V., Carrillo-Pérez, D.L., Rosado-Canto, R. et al. Electrolyte and Acid–Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 62, 1855–1871 (2017). https://doi.org/10.1007/s10620-017-4597-8

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