Risk Factors for Hepatic Hydrothorax in Cirrhosis Patients with Ascites - A Clinical Cohort Study

The Impact of Hepatic Hydrothorax on the Outcome of Liver Cirrhosis: A Comparative Study

Introduction: Hepatic hydrothorax (HH) is a severe cirrhosis complication requiring early diagnosis and appropriate management. This study aimed to assess the impact of HH on the disease severity and mortality of cirrhotic patients and compare their clinical and biological profiles with those of patients without HH. Materials and Methods: This retrospective study involved 155 patients diagnosed with cirrhosis, of whom 31 had HH. The diagnosis of HH was based on imaging techniques such as X-ray, ultrasound, and thoracic CT scans. The severity of cirrhosis was evaluated using the Child-Pugh, MELD, MELD-Na, and MELD 3.0 scoring systems. Results: Of the included patients, 83.87% (n = 26) were men, with a 20% incidence of HH. The main etiology was chronic alcohol use. The pleural fluid localization revealed similar numbers of patients with bilateral and right pleural distribution. Patients with HH were predominantly classified in Child-Pugh-Turcotte class C. The MELD, MELD-Na, and MELD 3.0 scores had higher median values in the group of patients with hepatic hydrothorax. Still, death occurred at lower MELD scores when compared with cirrhotic patients without HH (MELD score > 22.5 for patients with HH vs. MELD > 32.5 for patients without HH). (The cirrhotic patients with HH presented lower serum albumin, cholesterol, and triglyceride levels and higher bilirubin, INR, and creatinine values. The mortality rate was higher in the group with HH-58,06% versus 20.97% in the control group (cirrhotics without HH). Conclusions: Hepatic hydrothorax is a serious complication of cirrhosis that requires early recognition and proper management, supported by using biomarkers and scoring systems.

The CIRrhotic Ascites Severity (CIRAS) model predicts hepatic hydrothorax at all stages of ascites

BACKGROUND

Hepatic hydrothorax (HH) is a rare but severe manifestation of cirrhotic ascites. Whether HH development relates to ascites severity is uncertain and simple clinical models to predict HH from all stages of ascites are missing. The recently published CIRrhotic Ascites Severity (CIRAS) model using only ascites-related variables may serve this purpose.

AIM

We investigated if the CIRAS model within one year predicts the development of HH requiring thoracentesis in patients with cirrhosis and ascites.

METHODS

We used data from 1090 patients with cirrhosis and all severities of ascites enrolled in three randomized clinical trials with available CIRAS model scores and no history of HH. Fine and Gray regression was applied to estimate the CIRAS model's ability to predict HH.

RESULTS

Thirty-five patients developed HH requiring thoracentesis. The CIRAS model stratified patients at different risks for HH and increasing CIRAS score was associated with a higher risk for HH (sHR 1.49 [95% CI: 1.19-1.86]). The CIRAS model's discriminatory ability achieved an AUC of 0.67 (95% CI: 0.56-0.77); higher than of the cirrhosis severity scores Child-Pugh and MELD variants.

CONCLUSION

The CIRAS model predicts the development of HH in cirrhosis patients with any grade of ascites, suggesting a potential for improved pre-emptive HH management. This complements the general movement towards personalised treatments and care.

Pulmonary Complications of Portal Hypertension

Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important implications for management and liver transplantation (LT) candidacy. POPH is characterized by obstruction and remodeling of the pulmonary resistance arterial bed. Hepatopulmonary syndrome is the most common pulmonary vascular disorder, characterized by intrapulmonary vascular dilatations causing impaired gas exchange. LT may improve prognosis in select patients with POPH. LT is the only effective treatment of hepatopulmonary syndrome. Hepatic hydrothorax is defined as transudative pleural fluid accumulation that is not explained by primary cardiopulmonary or pleural disease. LT is the definitive cure for hepatic hydrothorax.

Risk factors for hepatic hydrothorax in patients with cirrhosis: a clinical retrospective study

Aims and background

Hepatic hydrothorax, which presents as an unexplained pleural effusion, is one of the important complications in patients with end-stage cirrhosis. It has a significant correlation with prognosis and mortality. The aim of this clinical study was to detect the risk factors for hepatic hydrothorax in patients with cirrhosis and to better understand potentially life-threatening complications.

Methods

Retrospectively, 978 cirrhotic patients who were hospitalized at the Shandong Public Health Clinical Center from 2013 to 2021 were involved in this study. They were divided into the observation group and the control group based on the presence of hepatic hydrothorax. The epidemiological, clinical, laboratory, and radiological characteristics of the patients were collected and analyzed. ROC curves were used to evaluate the forecasting ability of the candidate model. Furthermore, 487 cases in the experimental group were divided into left, right, and bilateral groups, and the data were analyzed.

Results

The patients in the observation group had a higher proportion of upper gastrointestinal bleeding (UGIB), a history of spleen surgery, and a higher model for end-stage liver disease (MELD) scores compared with the control group. The width of the portal vein (PVW) (P = 0.022), prothrombin activity (PTA) (P = 0.012), D-dimer (P = 0.010), immunoglobulin G (IgG) (P = 0.007), high-density lipoprotein cholesterol (HDL) (P = 0.022), and the MELD score were significantly associated with the occurrence of the hepatic hydrothorax. The AUC of the candidate model was 0.805 (P < 0.001, 95% CI = 0.758-0.851). Portal vein thrombosis was more common in bilateral pleural effusion compared with the left and right sides (P = 0.018).

Conclusion

The occurrence of hepatic hydrothorax has a close relationship with lower HDL, PTA, and higher PVW, D-dimer, IgG, and MELD scores. Portal vein thrombosis is more common in cirrhotic patients with bilateral pleural effusion compared to those with unilateral pleural effusion.

Hepatic hydrothorax does not increase the risk of death after transjugular intrahepatic portosystemic shunt in cirrhosis patients

OBJECTIVES

Hepatic hydrothorax (HH) is a predictor of poor survival in cirrhosis patients. However, whether HH increases the mortality risk of cirrhosis patients treated with transjugular intrahepatic portosystemic shunt (TIPS) is unknown. Our objective was to evaluate the influence of HH on the survival of cirrhosis patients after TIPS.

METHODS

Cirrhosis patients with portal hypertension complications were selected from a prospective database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to June 2021. Cirrhosis patients with HH were treated as the experimental group. A control group of cirrhosis patients without HH was created using propensity score matching. Survival after TIPS and the related risk factors were analysed.

RESULTS

There were 1292 cirrhosis patients with portal hypertension complications treated with TIPS, among whom 255 patients had HH. Compared with patients without HH, patients with HH had worse liver function (MELD, 12 vs. 10, p < 0.001), but no difference in survival after TIPS was observed. After propensity score matching, 243 patients with HH and 243 patients without HH were enrolled. There was no difference in cumulative survival between patients with and without HH. Cox regression analysis showed that HH was not associated with survival after TIPS, and main portal vein thrombosis (> 50%) was a prognostic factor of long-term survival after TIPS in cirrhosis patients (hazard ratio, 1.386; 95% CI, 1.030-1.865, p = 0.031).

CONCLUSION

Hepatic hydrothorax does not increase the risk of death after TIPS in cirrhosis patients.

KEY POINTS

• Hepatic hydrothorax is a decompensated event of cirrhosis and increases the risk of death. • Hepatic hydrothorax is associated with worse liver function. • Hepatic hydrothorax does not increase the mortality of cirrhosis treated with TIPS.

The impact and role of hepatic hydrothorax in the prognosis of patients with decompensated cirrhosis: A retrospective propensity score-matched study

Background and aims

Hepatic Hydrothorax (HH) is one of the complications in patients with decompensated cirrhosis and its impact and role in the prognosis of patients with decompensated cirrhosis are not yet clear. Thus, this study aimed to determine the role of HH in patients with decompensated cirrhosis and the long-term impact on their mortality.

Materials and methods

A retrospective study analyzed 624 patients with ascites without pleural effusion in decompensated cirrhosis and 113 patients with HH. Propensity scores were calculated based on eight variables, and the HH and non-HH groups were matched in a 1:1 ratio. The effect and role of HH on the prognosis of patients with decompensated cirrhosis was analyzed using the Kaplan-Meier method and Cox proportional hazards regression model.

Results

A total of 737 patients were included. Out of 113 HH patients, 106 could be matched to 106 non-HH patients. After matching, baseline characteristics were well-balanced. The multifactorial Cox proportional hazards model indicated that hepatic encephalopathy and HH were independent risk factors affecting prognostic survival in patients with decompensated cirrhosis (P < 0.01), with risk ratios and 95% confidence intervals (CI) of 2.073 (95% CI: 1.229-3.494, P < 0.01) and 4.724 (95% CI: 3.287-6.789, P < 0.01), respectively. Prognostic survival was significantly worse in the HH group compared to patients in the non-HH group, with mortality rates of 17.9, 30.1, and 59.4% at 6 months, 1 year, and 2 years in the HH group, compared to 0.9, 3.8, and 5.6% in the non-HH group, respectively. The estimated median survival time was 21 (95% CI: 18-25) months in the HH group and 49 (95% CI: 46-52) months in the non-HH group (P < 0.001).

Conclusion

Hepatic hydrothorax is significantly associated with higher mortality in patients with decompensated cirrhosis and is a highly negligible independent decompensated event affecting their prognosis.

Nonmalignant Pleural Effusions

Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

Analysis of clinical features and prognostic factors in patients with hepatic hydrothorax: a single-center study from China

BACKGROUND

The clinical features and factors affecting the prognostic survival of hepatic hydrothorax (HH) are currently unknown.

METHODS

We conducted a retrospective cohort study of 131 patients with HH using the Kaplan-Meier method and Cox proportional hazards regression analysis to assess factors influencing the prognosis of HH.

RESULTS

A total of 131 patients were enrolled: the male to female ratio was 80:51 (1.59:1), and the mean age was 52.76 ± 11.88 years. Hepatitis B cirrhosis was the main cause of HH, and abdominal distention and dyspnea were the most common clinical signs. Ascites was present in varying amounts in all patients and was the most common decompensated complication, with pleural effusions mostly seen on the right side (107/131; 82%), followed by the left side (16/131; 12%) and bilateral effusions (8/131; 6%). For overall survival without transplantation, the estimated median survival time was 21 (95% confidence interval [CI]:18-25) months, and survival rates at 6 months, 1 year, and 2 years were 77.2%, 62.4%, and 29.7%, respectively. After controlling for covariates that were associated with liver-related mortality in the univariate analysis, males (hazard ratio [HR]: 1.721, 95% CI: 1.114-2.658, P = 0.005) and combined hepatic encephalopathy (HR: 2.016, 95% CI: 1.101-3.693, P = 0.001) were found to be associated with an increase in liver-related mortality.

CONCLUSIONS

In this cohort of HH patients without liver transplantation, male sex and hepatic encephalopathy were associated with a higher risk of liver-related death.

Pulmonary complications of portal hypertension: The overlooked decompensation

The systemic nature of cirrhosis and portal hypertension has long been recognized, and the amount of data characterizing the interplay between each system is becoming ever so complex. Lung involvement was among the first described associated entities in cirrhosis, with reports dating back to the late nineteenth century. However, it appears that throughout the years, interest in the pulmonary complications of portal hypertension has generally faded, especially in contrast to other decompensating events, as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers. Despite affecting up to 10%-15% of patients with advanced liver disease and having a proven prognostic impact, hepato-pulmonary syndrome, porto-pulmonary hypertension, and hepatic hydrothorax are frequently misdiagnosed, mistreated, or misinterpreted. This lack of precision might adversely impact patient care, referral to expert centers, and, ultimately, liver disease-related mortality and successful transplantation odds. The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities. The paper focuses on the essential theoretical aspects, addressing the most critical knowledge gaps on the one hand and, on the other hand, critically discussing one key issue for each complication.