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Hyponatremia, Liver Transplantation and Tromethamine Availability

Published:September 24, 2022DOI:https://doi.org/10.1053/j.jvca.2022.09.087
      To the Editor:
      We read, with interest, Verbeek et al recent review of the perioperative implications and management of hyponatremia in liver transplant recipients .
      • Verbeek TA
      • Saner FH
      • Bezinover D.
      Hyponatremia and liver transplantation: A narrative review.
      We share their concerns with the inevitable sodium load associated with administration of sodium bicarbonate when used for management of metabolic acidosis during the transplant. Tromethamine was advocated for treatment of metabolic acidosis in the presence of severe hyponatremia, but its availability is limited.
      • Crismale JF
      • Meliambro KA
      • Demaria S
      • et al.
      Prevention of the osmotic demyelination syndrome after liver transplantation: A multidisciplinary perspective.
      ,
      • Rangrass G
      • Balogh J
      • Wagener G
      • et al.
      Trends in liver transplantation.
      In early 2018, the manufacturing company Hospira advised the Food and Drug Administration that the production of tromethamine had been discontinued and was unrelated to the drug's safety or efficacy. Liver transplant anesthesiologists worked with hospital pharmacy partners to locate a supply of tromethamine, which is also used as a component of commercial organ preservative solutions. Our pharmacy secured smaller volumes of tromethamine from a compounding pharmacy (Central Admixture Pharmacy Services), which has multiple locations across the United States, including one in Houston, Texas (Fig 1). The original source of tromethamine was a 500- mL glass bottle, which facilitated the large volumes often required during liver transplantation based on proportional correction of acidosis. The current supply is in 50- mL syringes, necessitating nuanced and partial correction along with other strategies as summarized by Verbeek.
      • Verbeek TA
      • Saner FH
      • Bezinover D.
      Hyponatremia and liver transplantation: A narrative review.
      Given the potentially devastating complications of rising plasma sodium during a liver transplant, tromethamine is an essential tool for anesthesiologists in the severely hyponatremic patient. Preparation of tromethamine by compounding pharmacies may allow limited access to the drug for use in liver transplantation.

      Conflicts of Interest

      None.

      References

        • Verbeek TA
        • Saner FH
        • Bezinover D.
        Hyponatremia and liver transplantation: A narrative review.
        J Cardiothorac Vasc Anesth. 2022; 36: 1458-1466
        • Crismale JF
        • Meliambro KA
        • Demaria S
        • et al.
        Prevention of the osmotic demyelination syndrome after liver transplantation: A multidisciplinary perspective.
        Am J Transplant. 2017; 17: 2537-2545
        • Rangrass G
        • Balogh J
        • Wagener G
        • et al.
        Trends in liver transplantation.
        ASA Monitor. 2021; 85: 31
      1. Available at: https://www.govinfo.gov/content/pkg/FR-2019-07-032019-14146.pdf/2019-14146.pdf Pages 31785-6. Accessed November 10, 2022.

      Linked Article

      • Hyponatremia and Liver Transplantation: A Narrative Review
        Journal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 5
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          Hyponatremia is a common electrolyte disorder in patients with end-stage liver disease (ESLD) and is associated with increased mortality on the liver transplantation (LT) waiting list. The impact of hyponatremia on outcomes after LT is unclear. Ninety-day and one-year mortality may be increased, but the data are conflicting. Hyponatremic patients have an increased rate of complications and longer hospital stays after transplant. Although rare, osmotic demyelination syndrome (ODS) is a feared complication after LT in the hyponatremic patient.
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