Hyponatremia is primarily a water balance disorder associated with high morbidity and mortality. The pathophysiological mechanisms behind hyponatremia are multifactorial, and diagnosing and treating this disorder remains challenging. In this review, the classification, pathogenesis, and step-by-step management approaches for hyponatremia in patients with liver disease are described based on recent evidence. We summarize the five sequential steps of the traditional diagnostic approach: 1) confirm true hypotonic hyponatremia, 2) assess the severity of hyponatremia symptoms, 3) measure urine osmolality, 4) classify hyponatremia based on the urine sodium concentration and extracellular fluid status, and 5) rule out any coexisting endocrine disorder and renal failure. Distinct treatment strategies for hyponatremia in liver disease should be applied according to the symptoms, duration, and etiology of disease. Symptomatic hyponatremia requires immediate correction with 3% saline. Asymptomatic chronic hyponatremia in liver disease is prevalent and treatment plans should be individualized based on diagnosis. Treatment options for correcting hyponatremia in advanced liver disease may include water restriction; hypokalemia correction; and administration of vasopressin antagonists, albumin, and 3% saline. Safety concerns for patients with liver disease include a higher risk of osmotic demyelination syndrome.
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High-dosage human albumin infusion may be superior for hypervolemic hyponatremia in cirrhosis with ascites Xianxian Zhang, Lu Chai, Haonan Zhao, Haitao Zhao, Ran Wang, Mauro Bernardi, Xingshun Qi Expert Review of Gastroenterology & Hepatology.2026; 20(3): 289. CrossRef
Hyponatremia in Cirrhosis: Comparative Evaluation of MELD and MELD-Na Scores for Predicting Short- and Long-Term Mortality Goutami V. Kohir, Nagaraj Kotli APIK Journal of Internal Medicine.2026; 14(1): 37. CrossRef
Accurate urine sodium measurements at home using point of care testing in patients with short bowel syndrome Miranda Van Berkel, Judith Beurskens-Meijerink, Nicole Buters-Ambrosius, Eline Van Der Hagen, Getty Huisman- De Waal, Geert Wanten Clinical Nutrition ESPEN.2025; 66: 262. CrossRef
Etiology, Clinical Approach, and Therapeutic Consequences of Hyponatremia Goce Spasovski Kidney and Dialysis.2024; 4(1): 37. CrossRef
Association of baseline serum sodium with long-term outcomes in newly diagnosed coronary heart disease patients without heart failure: a prospective cohort study Zelong Cao, Wenqing Zhu, Chaonan Shen, Bo Gao, Naying Jin, Fang Li, Bin Zhang, Gang Liu, Liang Zheng, Mingqi Zheng Scientific Reports.2024;[Epub] CrossRef
Correspondence on Letter regarding “Evidence-based hyponatremia management in liver disease” Ji Young Ryu, Seon Ha Baek, Sejoong Kim Clinical and Molecular Hepatology.2023; 29(4): 1048. CrossRef
Letter regarding “Evidence-based hyponatremia management in liver disease” Daphne J. Theodorou, Stavroula J. Theodorou, Ioannis V. Mitselos Clinical and Molecular Hepatology.2023; 29(4): 1043. CrossRef
Pulmonary Complications in Patients with Liver Cirrhosis Seul Ki Han, Soon Koo Baik, Moon Young Kim The Korean Journal of Gastroenterology.2023; 82(5): 213. CrossRef
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