title: Hyponatremia influences the outcome of patients with acute-on-chronic liver failure: an analysis of the CANONIC study.
abstract: BACKGROUND
  Hyponatremia is a marker of poor prognosis in patients with cirrhosis. This analysis aimed to assess if hyponatremia also has prognostic value in patients with acute-on-chronic liver failure (ACLF), a syndrome characterized by acute decompensation of cirrhosis, organ failure(s) and high short-term mortality.
  
  
  METHODS
  We performed an analysis of the Chronic Liver Failure Consortium CANONIC database in 1,341 consecutive patients admitted to 29 European centers with acute decompensation of cirrhosis (including ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infections, or any combination of these), both with and without associated ACLF (301 and 1,040 respectively).
  
  
  RESULTS
  Of the 301 patients with ACLF, 24.3% had hyponatremia at inclusion compared to 12.3% of 1,040 patients without ACLF (P <0.001). Model for end-stage liver disease, Child-Pugh and chronic liver failure-SOFA scores were significantly higher in patients with ACLF and hyponatremia compared to those without hyponatremia. The presence of hyponatremia (at inclusion or during hospitalization) was a predictive factor of survival both in patients with and without ACLF. The presence of hyponatremia and ACLF was found to have an independent effect on 90-day survival after adjusting for the potential confounders. Hyponatremia in non-ACLF patients nearly doubled the risk (hazard ratio (HR) 1.81 (1.33 to 2.47)) of dying at 90 days. However, when considering patients with both factors (ACLF and hyponatremia) the relative risk of dying at 90 days was significantly higher (HR 6.85 (3.85 to 12.19) than for patients without both factors. Patients with hyponatremia and ACLF had a three-month transplant-free survival of only 35.8% compared to 58.7% in those with ACLF without hyponatremia (P <0.001).
  
  
  CONCLUSIONS
  The presence of hyponatremia is an independent predictive factor of survival in patients with ACLF. In cirrhosis, outcome of patients with ACLF is dependent on its association with hyponatremia.
authors: GI Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. acardena@clinic.ub.es.
authors: Andrés
authors: A
authors: Cárdenas
authors: Liver Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. esola@clinic.ub.es.
authors: Elsa
authors: E
authors: Solà
authors: Liver Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. ezrodrig@clinic.ub.es.
authors: Ezequiel
authors: E
authors: Rodríguez
authors: Liver Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. rbarreto@clinic.ub.es.
authors: Rogelio
authors: R
authors: Barreto
authors: Liver Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. igraupe@clinic.ub.es.
authors: Isabel
authors: I
authors: Graupera
authors: Data Management Center - CLIF Consortium, Hospital Clinic, Carrer Villarroel, 170, 08036, Barcelona, Spain. mpavesi@clinic.ub.es.
authors: Marco
authors: M
authors: Pavesi
authors: AP-HP Hôpital Paul Brousse Centre Hépato-Biliaire, University Paris-Sud, UMR-S 785, 12 avenue Paul Vaillant Couturier, 94800, Villejuif, France. faouzi.saliba@pbr.aphp.fr.
authors: Faouzi
authors: F
authors: Saliba
authors: Department of Medicine 1, JW Goethe University Hospital, Frankfurt Theodor-Stern-Kai 7, D-60590, Frankfurt am Main, Germany. Tania.Welzel@kgu.de.
authors: Tania Mara
authors: TM
authors: Welzel
authors: Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera. de Colmenar Viejo, km 9100, 28034, Madrid, Spain. martinez.gonzalez.javier@gmail.com.
authors: Javier
authors: J
authors: Martinez-Gonzalez
authors: Liver Unit, Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium. Thierry.Gustot@erasme.ulb.ac.be.
authors: Thierry
authors: T
authors: Gustot
authors: Department of Medical and Surgical Sciences, University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy. mauro.bernardi@unibo.it.
authors: Mauro
authors: M
authors: Bernardi
authors: Liver Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. varroyo@clinic.ub.es.
authors: Vicente
authors: V
authors: Arroyo
authors: Liver Unit, Hospital Clinic, University of Barcelona, Carrer Villarroel, 170, 08036, Barcelona, Spain. pgines@clinic.ub.es.|University of Barcelona, IDIBAPS, CIBEReHD, IRSIN, Carrer Villarroel, 170, 08036, Barcelona, Catalunya, Spain. pgines@clinic.ub.es.
authors: Pere
authors: P
authors: Ginès
mesh_terms: D065290:Acute-On-Chronic Liver Failure / Q000150:complications / Q000401:mortality*; D000328:Adult; D000368:Aged; D058625:End Stage Liver Disease / Q000401:mortality; D005260:Female; D006801:Humans; D007010:Hyponatremia / Q000150:complications*; D008103:Liver Cirrhosis / Q000150:complications; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012720:Severity of Illness Index
references: J Hepatol. 2010 Sep;53(3):397-417
references: 20633946
references: Hepatology. 2004 Oct;40(4):802-10
references: 15382176
references: Gastroenterology. 2006 Apr;130(4):1135-43
references: 16618408
references: Pediatr Nephrol. 2006 Oct;21(10):1487-8; author reply 1489
references: 16897000
references: J Hepatol. 2014 Nov;61(5):1038-47
references: 24950482
references: Hepatology. 2008 Sep;48(3):1002-10
references: 18671303
references: J Hepatol. 2012 Dec;57(6):1336-48
references: 22750750
references: Gut. 2006 Oct;55 Suppl 6:vi1-12
references: 16966752
references: Gastroenterology. 2013 Jun;144(7):1426-37, 1437.e1-9
references: 23474284
references: Clin Gastroenterol Hepatol. 2006 Nov;4(11):1385-94
references: 17081806
references: N Engl J Med. 2008 Sep 4;359(10):1018-26
references: 18768945
references: Hepatology. 2006 Dec;44(6):1535-42
references: 17133458
references: Pediatr Nephrol. 2006 Jun;21(6):778-81
references: 16565868
references: Liver Int. 2009 Aug;29(7):1071-7
references: 19302181
references: Gut. 2007 Sep;56(9):1283-90
references: 17452425
references: Hepatology. 2005 Jan;41(1):32-9
references: 15690479
references: Arch Intern Med. 2002 Feb 11;162(3):323-8
references: 11822925
references: Am J Dig Dis. 1976 Mar;21(3):249-56
references: 1266841
references: Gastroenterology. 2014 Jul;147(1):4-10
references: 24853409
references: Dig Liver Dis. 2000 Oct;32(7):605-10
references: 11142560
references: Nephron Physiol. 2011;118(2):45-51
references: 21196778
references: J Hepatol. 1995 Aug;23(2):123-8
references: 7499782
references: Liver Transpl. 2007 Aug;13(8):1115-24
references: 17663412
references: Korean J Pediatr. 2013 Dec;56(12):519-22
references: 24416046