Prevention of the Osmotic Demyelination Syndrome After Liver Transplantation: A Multidisciplinary Perspective

The osmotic demyelination syndrome ( ODS ) is a serious neurologic condition that occurs in the setting of rapid correction of hyponatremia. It presents with protean manifestations, from encephalopathy to the “locked‐in” syndrome. ODS can complicate liver transplantation ( LT ), and its incidence may increase with the inclusion of serum sodium as a factor in the Mayo End‐Stage Liver Disease score. A comprehensive understanding of risk factors for the development of ODS in the setting of LT , along with recommendations to mitigate the risk of ODS , are necessary. The literature to date on ODS in the setting of LT was reviewed. Major risk factors for the development of ODS include severe pretransplant hyponatremia (serum sodium [ SN a] < 125 mEq/L), the magnitude of change in SN a pre‐ versus posttransplant, higher positive intraoperative fluid balance, and the presence of postoperative hemorrhagic complications. Strategies to reduce the risk of ODS include correcting hyponatremia pretransplant via fluid restriction and/or ensuring an appropriate rate of increase from the preoperative SN a via close attention to fluid and electrolyte management both during and after surgery. Multidisciplinary management involving transplant hepatology, nephrology, neurology, surgery, and anesthesiology/critical care is key to performing LT safely in patients with hyponatremia.