IMPACT OF RENAL PROFILE AND SERUM SODIUM ON PATIENTS WITH END STAGE LIVER DISEASE ( CTP – C ) : A HOSPITAL BASED PROSPECTIVE STUDY FROM SUB-HIMALAYAN RURAL AREA

Abstract

BACKGROUND : Himachal Pradesh with a population with 68,64,602 is situated in the Northern part of India and is
mainly a hilly state. Dr.Rajendra Prasad Government Medical College & Hospital in district Kangra is the only major
referral hospital in this part of the state catering to approximately 60% of the population of the state mainly of rural background.. In this study End
Stage Liver Disease has been defined by Child Turcot Pugh i.e CTP – C . Creatinine is produced in patients with cirrhosis lower than the the
normal rate. Lower serum creatinine values lead to over-estimation of renal function by predictive equations , which can result in higher
creatinine clearance calculated from timed urine collection compared with true GFR. Hyponatremia is a frequent complication of advanced
cirrhosis. Hyponatremia in cirrhosis is associated with increased morbidity and mortality. There is evidence suggesting that hyponatremia may
affect brain function and predispose to hepatic encephalopathy. We have designed the study to evaluate the impact of serum sodium and
creatinine on 6 month mortality.
1. M ost of the available literature on this topic from studies based on urban population and studies in developed countries. Moreover the
inference from studies on western population or urban population may not be uniformly applicable to the rural.
2. S erum creatinine can not be a reliablemarker for mortality in cirrhosis as it may underestimate renal dysfunction.
3. I n literature most of the study on hyponatremia was done in cirhhosis ( CTP-A to CTP –C ) but serum sodium may have a greater implication
on patients with end stage renal disease, so we have included only CTP-C cirrhosis here.
METHOD : It is hospital based prospective study . The study has been conducted for a period of 15 months that include 9 months of data
collection and 6 months of follow-up in all patient admitted in medicine department of Dr. RPGMC ,Tanda. Sample size is 100. Data have been
analysed using computer software MS Excel. Primary end point death has been observed in patients with CTP C ESLD with the impact of serum
sodium and renal profile on mortality.
RESULTS : Mean serum sodium level in study population was 130.83 mmol / L . Patient who died in 6 months had mean serum sodium level of
124.24 mmol/L and who survived had a level of 137.42 mmol/L . And this value was significant for 6 month mortality ( P value < .05 ). In our
study hyponatremia was associated with significant 6 month mortalilty which corresponds with other studies. Apart from mortality low serum
sodium was associated with increased decompensation related hospital admission , HE and SBP. Serum creatinine mean value was 1.885 mg /
dL. Patient who died by 6 months had value of 2.03 mg / dL and among survived patients it was 1.74 mg , but it was not stasistically significant. In
our study high serum creatinine was not associated with significant mortality in end stage liver disease. Reasons of which may be attributable to
low sample size , short follow-up period , prevalence of prerenal AKI and drug induced AKI which was corrected by albumin infusion or
withdrawal of offending drugs.
CONCLUSION : Hyponatremia has a negative impact on survival of patients with ESLD. It is associated with hepatic encephalopathy , SBP ,
decompensation related hospital admission and death. Identifying hyponatremia in patient with ESLD is very important whereas renal
dysfunction is ESLD is mostly avoidable and treatable. Judicial use of diuretics , contrast agents and water restriction can prevent hyponatremia
in large group of patients. Pre-renal or drug induced azotemia can be treated succesfully by administration of albumin and withdrawal of
offending drugs.