Osmotic Demyelination Syndrome Following Hyponatremia-Oriented Management in Liver Transplant: A Single Center 20-Year Experience

Objectives: Liver transplant recipients are at high risk of developing osmotic demyelination syndrome because of electrolyte imbalance, fluid management, transfusion, and administration of immunosuppressive agents during the perioperative period. During the first 9 years of liver transplant procedures conducted at our institution, we experienced 5 cases (1.2%) of osmotic demyelination syndrome in 402 transplant recipients. We established a hyponatremia-oriented management protocol to carefully monitor sodium concentration during and after transplant in patients with preoperative hyponatremia. Here, our aim was to investigate the incidence of this syndrome posttransplant in patients who received hyponatremia-oriented management at our center. Materials and Methods: We retrospectively reviewed the medical records of 1437 patients who underwent liver transplant between 2005 and 2017, after hyponatremia-oriented management had been established at our center. We evaluated predisposing conditions, clinical parameters, and biological parameters of patients who were diagnosed with osmotic demyelination syndrome posttransplant. Results: Of 1437 patients, 4 (0.28%) were diagnosed with osmotic demyelination syndrome based on neuroimaging findings. All 4 patients were in chronic hyponatremia pretransplant (range, 110-118 mEq/L), including 3 who experienced rapid changes of sodium (over 8 mEq/L/day) within 1 month pretransplant and 1 who had rapid increase of sodium during postoperative care. The incidence of osmotic demyelination syndrome was decreased by hyponatremia-oriented management with favorable outcome. Conclusions: To decrease the incidence of osmotic demyelination syndrome, we should focus on identifying patients at higher risk and apply appropriate management of fluids and electrolytes before liver transplant.