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Fathma S, Boateng S, Amatya A, Ameyaw P, Banini BA. The impact of MELD exception points for hydrothorax on posttransplant mortality: a propensity score-matched analysis. Eur J Gastroenterol Hepatol 2024; 36:1016-1021. [PMID: 38829948 PMCID: PMC11230850 DOI: 10.1097/meg.0000000000002792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Hepatic hydrothorax is a challenging complication of end-stage liver disease, and.patients with this complication can receive model for end-stage liver disease (MELD) exception points if they meet specific criteria as defined by United Network for Organ Sharing (UNOS). This research aimed to analyze the effect of receiving MELD exception points for hepatic hydrothorax on posttransplant mortality, using a national transplant database. METHODS Patients >18 years in the UNOS database awaiting liver transplant between 2012 and 2023 were identified based on their petition for MELD exception points. Using a 1: 1 propensity score-matched analysis, 302 patients who received MELD exception points for hepatic hydrothorax were compared with 302 patients who did not receive MELD exception points.Demographic, clinical and laboratory values were compared. The primary outcome was posttransplant mortality. Multivariate logistic regression controlled for potential confounders. RESULTS No significant difference was observed in mean age (58.20 vs 57.62 years), mean initial MELD score (16.93 vs 16.54), or mean Child-Pugh score (9.77 vs 9.74) in patients with hepatic hydrothorax receiving MELD exception points versus their matched cohort who did not recieve exception points. The proportion of males was slightly higher among patients who received MELD exception points (57.6% males vs 53.6% males). A majority of patients in both groups had Child-Pugh grade C (>56%). Patients receiving MELD exception points for hepatic hydrothorax had a statistically significant 44% decrease in the odds of posttransplant death compared to those who did not (OR 0.56; 95% CI 0.37-0.88; P = 0.01). Among the combined cohort, each year increase in age resulted in a 3.9% increase in mortality (OR 1.04; 95% CI 1.01-1.07; P = 0.005), and every one-unit increase in serum creatinine resulted in a 40% increase in mortality (OR 1.40; 95% CI 1.03-1.92; P = 0.03). CONCLUSION Receiving MELD exception points for hepatic hydrothorax is associated with a significant reduction in the odds of posttransplant mortality. These findings underscore the importance of MELD exception points for hepatic hydrothorax among patients with decompensated cirrhosis, potentially improving patient prioritization for liver transplantation and influencing clinical decision-making.
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Affiliation(s)
- Sawsan Fathma
- Department of Internal Medicine, Waterbury Hospital, Waterbury
| | - Sarpong Boateng
- Department of Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport
| | - Ayesha Amatya
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Prince Ameyaw
- Department of Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport
| | - Bubu A Banini
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
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Wilkins H, Britt E, Bhatnagar M, Pippard B. Hepatic hydrothorax. J Thorac Dis 2024; 16:1662-1673. [PMID: 38505059 PMCID: PMC10944768 DOI: 10.21037/jtd-23-1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.
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Affiliation(s)
- Hannah Wilkins
- Department of Gastroenterology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ellie Britt
- Department of Respiratory Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK
| | - Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK
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Nagai A, Sugimoto K, Yamamoto T, Wakabayashi H, Kaneda S, Nakagawa N, Yamamoto N. A case of refractory hepatic hydrothorax due to pleuroperitoneal communication successfully controlled by diaphragmatic plication and subsequent peritoneovenous shunting. Clin J Gastroenterol 2024; 17:137-142. [PMID: 38032453 DOI: 10.1007/s12328-023-01889-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023]
Abstract
In general, control of hepatic hydrothorax is difficult, and patients have a poor prognosis. A case in which hepatic hydrothorax was well controlled for a long time after diaphragm plication and subsequent Denver shunt placement is reported. A 70-year-old man with decompensated liver cirrhosis presented with progressive exertional dyspnea. 5 years before admission, hepatic ascites associated with portal hypertension appeared, and a left pleural effusion subsequently developed. The pleural effusion was not controlled by salt restriction and diuretics. Based on the clinical findings, the existence of pleuroperitoneal communication was strongly suspected, and surgical diaphragmatic plication was performed. After the treatment, the pleural effusion did not accumulate, but ascites increased significantly, and conservative therapy was ineffective. For the treatment of massive ascites, a peritoneovenous shunt (Denver shunt®) was placed. Although more than 2 years have passed, the thoracoabdominal effusions have not accumulated, and the patient has been asymptomatic. The present case suggests that multidisciplinary treatment may improve the prognosis of patients with refractory thoracoabdominal effusions.
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Affiliation(s)
- Arisa Nagai
- Department of General Medicine, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazushi Sugimoto
- Department of Clinical Laboratory, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takayuki Yamamoto
- Department of General Medicine, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hideki Wakabayashi
- Department of General Medicine, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shinji Kaneda
- Department of Thoracic Surgery and Cardiovascular Surgery, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naoki Nakagawa
- Kuwana City Medical Center, 3-11 Kotobuki Town, Kuwana, Mie, 511-0061, Japan
| | - Norihiko Yamamoto
- Department of General Medicine, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
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Osman KT, Naritsin A, Amuchi B, Qamar AA. Liver transplantation for refractory hepatic hydrothorax is associated with a greater survival benefit compared to other complications of cirrhosis. Liver Transpl 2024; 30:142-150. [PMID: 37450656 DOI: 10.1097/lvt.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
Hepatic hydrothorax (HH) is a significant complication of cirrhosis associated with increased mortality. Liver transplantation (LT) remains the best treatment modality. We aim to assess predictors of mortality and the survival benefit of LT in patients with HH. A prospectively maintained cohort of adult patients with cirrhosis, being evaluated for LT at our institution, was retrospectively reviewed from 2015 to 2020. The primary outcome was death or LT. Cox proportional hazard regression identified associations between covariates and death. We calculated the years saved due to LT by comparing patients who were on the waiting list with patients who received an LT. This was done by calculating the area under the Kaplan-Meier curve. Censoring occurred at the time of the last follow-up or death. Patients with refractory HH had the lowest median survival of only 0.26 years. Within the HH group, having a refractory HH group was significantly associated with an increased risk of mortality (HR 1.73; 95% CI 1.06-2.81; p -value 0.03). Refractory HH was also significantly associated with mortality when evaluated in the entire cohort and after adjusting for other covariates (HR 1.48, 95% CI 1.03-2.11; p -value 0.03). Patients with refractory HH had the highest 1-year survival benefit with LT (0.48 y), followed by patients with non-refractory HH (0.28 y), then patients with other complications of cirrhosis (0.19 y). In this large study evaluating the prognostic impact of HH on patients with cirrhosis, refractory HH was an independent predictor of mortality. LT provides an additional survival benefit to patients with HH compared with those without HH.
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Affiliation(s)
- Karim T Osman
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Anastasia Naritsin
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Brenda Amuchi
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Amir A Qamar
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Division of Transplant and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
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Han SK, Baik SK, Kim MY. [Pulmonary Complications in Patients with Liver Cirrhosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:213-223. [PMID: 37997217 DOI: 10.4166/kjg.2023.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023]
Abstract
Portal hypertension is a clinical syndrome defined by an increased portal venous pressure. The most frequent cause of portal hypertension is liver cirrhosis, and many of the complications of cirrhosis, such as ascites and gastroesophageal variceal bleeding, are related to portal hypertension. Portal hypertension is a pathological condition caused by the accumulation of blood flow in the portal system. This blood flow retention reduces the effective circulation volume. To compensate for these changes, neurotransmitter hormone changes and metabolic abnormalities occur, which cause complications in organs other than the liver. A hepatic hydrothorax is fluid accumulation in the pleural space resulting from increased portal pressure. Hepatopulmonary syndrome and portopulmonary hypertension are the pulmonary complications in cirrhosis by deforming the vascular structure. Symptoms, such as dyspnea and hypoxia, affect the survival and the quality of life of patients. These lung complications are usually underestimated in the management of cirrhosis. This review briefly introduces the type of lung complications of cirrhosis.
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Affiliation(s)
- Seul Ki Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regeneration Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
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Cadranel JFD, Ollivier-Hourmand I, Cadranel J, Thevenot T, Zougmore H, Nguyen-Khac E, Bureau C, Allaire M, Nousbaum JB, Loustaud-Ratti V, Causse X, Sogni P, Hanslik B, Bourliere M, Peron JM, Ganne-Carrie N, Dao T, Thabut D, Maitre B, Debzi N, Smadhi R, Sombie R, Kpossou R, Nouel O, Bissonnette J, Ruiz I, Medmoun M, Dastis SN, Deltenre P, Artru F, Raherison C, Elkrief L, Lemagoarou T. International survey among hepatologists and pulmonologists on the hepatic hydrothorax: plea for recommendations. BMC Gastroenterol 2023; 23:305. [PMID: 37697230 PMCID: PMC10496231 DOI: 10.1186/s12876-023-02931-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/23/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND The Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax. METHODS Practitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management. RESULTS Five hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists; p = 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists; p = 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists; p < 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists; p < 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (p < 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists; p = 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (p < 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists; p < 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists; p < 0.001). CONCLUSIONS The results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted.
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Affiliation(s)
| | | | | | | | - Honoré Zougmore
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
| | | | | | - Manon Allaire
- Hepatogastroenterology Department, La Pitié Salpétrière, Paris, France
| | | | | | | | | | | | - Marc Bourliere
- Hepatogastroenterology department, Saint-Joseph, Marseille, France
| | | | | | - Thong Dao
- Hepatogastroenterology department, CHU Caen, Caen, France
| | - Dominique Thabut
- Hepatogastroenterology Department, La Pitié Salpétrière, Paris, France
| | | | - Nabil Debzi
- Hepatology Department CHU Mustapha, Alger, Algérie, Algeria
| | - Ryad Smadhi
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
- Hepatology Department CHU Mustapha, Alger, Algérie, Algeria
| | - Roger Sombie
- Gastroenterology Department, CHU Yalgado Ouedraogo Ouagadougou, Ouagadougou, Burkina Faso
| | - Raimi Kpossou
- Hepatogastroenterology Deparment, National Hospital and University Center Hubert Koutoukou Maga, Cotonou, Benin
| | - Olivier Nouel
- Hepatogastroenterology Department, St Brieuc, France
| | - Julien Bissonnette
- Department of Hepatology and Liver Transplantation, University of Montreal Hospital, Montreal, Canada
| | - Isaac Ruiz
- Department of Hepatology and Liver Transplantation, University of Montreal Hospital, Montreal, Canada
| | - Mourad Medmoun
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
| | | | | | - Florent Artru
- Hepatogastroenterology Department, Lausanne, Suisse, Switzerland
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Porcel JM. Expert Review on Contemporary Management of Common Benign Pleural Effusions. Semin Respir Crit Care Med 2023. [PMID: 37263288 DOI: 10.1055/s-0043-1769096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Heart failure (HF) and cirrhosis are frequently associated with pleural effusions (PEs). Despite their apparently benign nature, both HF-related effusions and hepatic hydrothorax (HH) have poor prognosis because they represent an advanced stage of the disease. Optimization of medical therapy in these two entities involve not only the use of diuretics, but also other pharmacological therapies. For instance, all HF patients with reduced or mildly reduced left ventricular ejection fraction can benefit from angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Conversely, it is better for HH patients to avoid nonselective beta blockers. Refractory cardiac- and cirrhosis-related PEs are commonly managed by iterative therapeutic thoracentesis. When repeated aspirations are needed, thereby diminishing quality of life, the insertion of an indwelling pleural catheter (IPC) may be warranted. However, in selected HH patients who are diuretic-resistant or diuretic-intractable, placement of transjugular intrahepatic portosystemic shunts should be considered as a bridge to liver transplantation, whereas in transplant candidates the role of IPC is debatable. Another benign condition, pleural tuberculosis (TB) is a serious health problem in developing countries. Diagnostic certainty is still a concern due to the paucibacillary nature of the infection, although the use of more sensitive nucleic acid amplification tests is becoming more widespread. Its treatment is the same as that of pulmonary TB, but the potential drug interactions between antiretroviral and anti-TB drugs in HIV-coinfected patients as well as the current recommended guidelines for the different types of anti-TB drugs resistance should be followed.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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Bai X, Liu X, Shi Y, Li W, Li Q, Du W. Risk factors for hepatic hydrothorax in patients with cirrhosis: a clinical retrospective study. Front Med (Lausanne) 2023; 10:1165604. [PMID: 37332757 PMCID: PMC10268603 DOI: 10.3389/fmed.2023.1165604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023] Open
Abstract
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.
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Affiliation(s)
- Xue Bai
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyan Liu
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Yanhui Shi
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Qiang Li
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Wenjun Du
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
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Evaluation of first and second trimester maternal thyroid profile on the prediction of gestational diabetes mellitus and post load glycemia. PLoS One 2023; 18:e0280513. [PMID: 36638142 PMCID: PMC9838876 DOI: 10.1371/journal.pone.0280513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/02/2023] [Indexed: 01/14/2023] Open
Abstract
Maternal thyroid alterations have been widely associated with the risk of gestational diabetes mellitus (GDM). This study aims to 1) test the first and the second trimester full maternal thyroid profile on the prediction of GDM, both alone and combined with non-thyroid data; and 2) make that prediction independent of the diagnostic criteria, by evaluating the effectiveness of the different maternal variables on the prediction of oral glucose tolerance test (OGTT) post load glycemia. Pregnant women were recruited in Concepción, Chile. GDM diagnosis was performed at 24-28 weeks of pregnancy by an OGTT (n = 54 for normal glucose tolerance, n = 12 for GDM). 75 maternal thyroid and non-thyroid parameters were recorded in the first and the second trimester of pregnancy. Various combinations of variables were assessed for GDM and post load glycemia prediction through different classification and regression machine learning techniques. The best predictive models were simplified by variable selection. Every model was subjected to leave-one-out cross-validation. Our results indicate that thyroid markers are useful for the prediction of GDM and post load glycemia, especially at the second trimester of pregnancy. Thus, they could be used as an alternative screening tool for GDM, independently of the diagnostic criteria used. The final classification models predict GDM with cross-validation areas under the receiver operating characteristic curve of 0.867 (p<0.001) and 0.920 (p<0.001) in the first and the second trimester of pregnancy, respectively. The final regression models predict post load glycemia with cross-validation Spearman r correlation coefficients of 0.259 (p = 0.036) and 0.457 (p<0.001) in the first and the second trimester of pregnancy, respectively. This investigation constitutes the first attempt to test the performance of the whole maternal thyroid profile on GDM and OGTT post load glycemia prediction. Future external validation studies are needed to confirm these findings in larger cohorts and different populations.
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Osman KT, Abdelfattah AM, Mahmood SK, Elkhabiry L, Gordon FD, Qamar AA. Refractory Hepatic Hydrothorax Is an Independent Predictor of Mortality When Compared to Refractory Ascites. Dig Dis Sci 2022; 67:4929-4938. [PMID: 35534742 DOI: 10.1007/s10620-022-07522-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 02/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatic hydrothorax (HHT) is an uncommon but significant complication of cirrhosis and portal hypertension, associated with a worse prognosis and mortality. Nearly 25% of patients with HHT will have refractory pleural effusion. It is unclear if refractory HHT has a different prognosis compared to refractory ascites. AIMS We aim to evaluate the prognostic significance of refractory HHT when compared to refractory ascites. METHODS Forty-seven patients who had refractory HHT in a tertiary care center were identified, and matched, retrospectively, one-to-one by age, gender and MELD-Na with 47 patients with refractory ascites. One-year mortality rate was compared between both groups. Cox proportional hazard regression was used to identify the association between different covariates and primary endpoint. RESULTS The 1-year mortality was 51.06% in the HHT group compared to 19.15% in the refractory ascites group. The median survival for patients with refractory hepatic hydrothorax was 4.87 months while the median survival for patients with refractory ascites exceeded 1 year. The presence of HHT was statistically significant in predicting the development of 1-year mortality [Hazard Ratio (HR) 4.45, 95% Confidence Interval (CI) 2.25-8.82; P value < 0.001]. Furthermore, refractory HHT remained associated with one-year mortality after adjusting for all other covariates. In a subgroup of patients with MELD-Na ≤ 20, HHT continued to be a significant predictor of one-year mortality (HR 3.30, 95% CI 1.47-7.40; P value 0.004). CONCLUSIONS Refractory HHT is a significant independent predictor of mortality and offers additional prognostic value.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA.
| | - Ahmed M Abdelfattah
- Department of Gastroenterology, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA
| | - Syed K Mahmood
- Department of Gastroenterology, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Fredric D Gordon
- Department of Transplant and Hepatobiliary Diseases, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Amir A Qamar
- Department of Transplant and Hepatobiliary Diseases, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA, 01805, USA.,Tufts University School of Medicine, Boston, MA, USA
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11
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Romero S, Lim AKH, Singh G, Kodikara C, Shingaki-Wells R, Chen L, Hui S, Robertson M. Natural history and outcomes of patients with liver cirrhosis complicated by hepatic hydrothorax. World J Gastroenterol 2022; 28:5175-5187. [PMID: 36188717 PMCID: PMC9516676 DOI: 10.3748/wjg.v28.i35.5175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/28/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic hydrothorax (HH) is an uncommon and difficult-to-manage complication of cirrhosis with limited treatment options.
AIM To define the clinical outcomes of patients presenting with HH managed with current standards-of-care and to identify factors associated with mortality.
METHODS Cirrhotic patients with HH presenting to 3 tertiary centres from 2010 to 2018 were retrospectively identified. HH was defined as pleural effusion in the absence of cardiopulmonary disease. The primary outcomes were overall and transplant-free survival at 12-mo after the index admission. Cox proportional hazards analysis was used to determine factors associated with the primary outcomes.
RESULTS Overall, 84 patients were included (mean age, 58 years) with a mean model for end-stage liver disease score of 29. Management with diuretics alone achieved long-term resolution of HH in only 12% patients. At least one thoracocentesis was performed in 73.8% patients, transjugular intrahepatic portosystemic shunt insertion in 11.9% patients and 33% patients received liver transplantation within 12-mo of index admission. Overall patient survival and transplant-free survival at 12 mo were 68% and 41% respectively. At multivariable analysis, current smoking [hazard ratio (HR) = 8.65, 95% confidence interval (CI): 3.43-21.9, P < 0.001) and acute kidney injury (AKI) (HR = 2.91, 95%CI: 1.21-6.97, P = 0.017) were associated with a significantly increased risk of mortality.
CONCLUSION Cirrhotic patients with HH are a challenging population with a poor 12-mo survival despite current treatments. Current smoking and episodes of AKI are potential modifiable factors affecting survival. HH is often refractory of diuretic therapy and transplant assessment should be considered in all cases.
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Affiliation(s)
- Sarah Romero
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
| | - Andy KH Lim
- Department of General Medicine, School of Clinical Sciences, Monash University, Clayton 3168, Victoria, Australia
| | - Gurpreet Singh
- Gastroenterology and Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Chamani Kodikara
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
| | | | - Lynna Chen
- Gastroenterology and Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Samuel Hui
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
| | - Marcus Robertson
- Department of Gastroenterology, Monash Health, Clayton 3168, Victoria, Australia
- Department of General Medicine, School of Clinical Sciences, Monash University, Clayton 3168, Victoria, Australia
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12
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Ma B, Shang T, Huang J, Tu Z, Wang Y, Han Y, Wen X, Jin Q. The impact and role of hepatic hydrothorax in the prognosis of patients with decompensated cirrhosis: A retrospective propensity score-matched study. Front Med (Lausanne) 2022; 9:904414. [PMID: 36148461 PMCID: PMC9485448 DOI: 10.3389/fmed.2022.904414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Bo Ma
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Tianling Shang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jianjie Huang
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zhixin Tu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yan Wang
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yujin Han
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xiaoyu Wen
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Qinglong Jin
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
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13
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Pippard B, Bhatnagar M, McNeill L, Donnelly M, Frew K, Aujayeb A. Hepatic Hydrothorax: A Narrative Review. Pulm Ther 2022; 8:241-254. [PMID: 35751800 PMCID: PMC9458779 DOI: 10.1007/s41030-022-00195-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8-12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.
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Affiliation(s)
- Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Lisa McNeill
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mhairi Donnelly
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katie Frew
- Department of Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, Northumbria Way, Northumberland, Cramlington, NE23 6NZ, UK.
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14
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Porcel JM. Nonmalignant Pleural Effusions. Semin Respir Crit Care Med 2022; 43:570-582. [PMID: 36104027 DOI: 10.1055/s-0042-1748186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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15
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Awiwi MO, Elsayes KM, Mohamed YI, Altameemi L, Gjoni M, Irshad OM, Sayed Ahmed A, Kaseb AO, Salem U. The Prognostic Value of Baseline Clinical and Radiologic Imaging Features in Patients with Unresectable Hepatocellular Carcinoma Treated with Atezolizumab Plus Bevacizumab. J Hepatocell Carcinoma 2022; 9:913-927. [PMID: 36065424 PMCID: PMC9440709 DOI: 10.2147/jhc.s379428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose To identify prognostic clinical and radiologic features in patients with unresectable hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab. Patients and Methods Clinical and imaging records of patients with unresectable HCC were retrospectively reviewed, and baseline features were recorded. Patients’ records and imaging studies were used to determine the patients’ overall survival (OS) and progression-free survival (PFS). Univariate and multivariate analyses were performed to determine prognostic features. Subanalyses of treatment-naïve patients (who never received local or systemic therapy) and previously treated patients were also performed. Results Fifty-five patients were included in the final analysis, 23 (41.8%) of whom were treatment naïve. The median PFS and OS for the entire cohort were 3.0 months and 7.9 months. The 3-, 6- and 12-month OS rates were 85.5%, 79.8% and 45.7%, respectively. The 3-, 6- and 12-month PFS rates were 50.1%, 41.2% and 20.1%, respectively. On multivariate analysis, independent prognostic features for poor PFS of the entire cohort were pleural effusions (p = 0.047, HR: 6.3; CI: 1.03–38.90) and hepatic vein tumor thrombus (p = 0.005; HR: 23.37; CI: 2.63–207.67); independent prognostic features for poor OS were ascites (p = 0.008; HR: 37.37; CI: 2.53–467.64), pleural effusion (p = 0.003; HR: 110.17; CI: 5.00–2426.54), and low (<40HU) pre-contrast attenuation on CT images (p = 0.007; HR: 0.09; CI: 0.02–0.53). On subanalysis of treatment-naïve patients, the median OS and PFS were 7.4 months and 2.8 months, respectively. The 3-, 6- and 12-month PFS rates were 43.5%, 38.6% and 24.8%, respectively. Pleural effusion was the only independent poor prognostic feature (p = 0.036; HR: 206.34; CI: 1.41–30,167.58). Conclusion Independent prognostic features for survival outcomes include the presence of ascites, pleural effusions, hepatic vein tumor thrombus, and HCC with low attenuation (<40 HU) on unenhanced CT images. Although several biochemical variables were significant on univariate analysis, none were independent predictors of OS or PFS.
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Affiliation(s)
- Muhammad O Awiwi
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Khaled M Elsayes
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Correspondence: Khaled M Elsayes, 1515 Holcombe Blvd, Houston, TX, 77030, USA, Tel +1 877 632-6789, Fax +1 713 794-4535, Email
| | - Yehia I Mohamed
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lina Altameemi
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Migena Gjoni
- Department of Internal Medicine, The of Istanbul-Cerrahpasa Hospital, Istanbul, Turkey
| | | | - Ahmed Sayed Ahmed
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmad O Kaseb
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Usama Salem
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Deleuran T, Watson H, Vilstrup H, Jepsen P. Risk Factors for Hepatic Hydrothorax in Cirrhosis Patients with Ascites - A Clinical Cohort Study. Dig Dis Sci 2022; 67:3395-3401. [PMID: 34191185 DOI: 10.1007/s10620-021-07134-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/20/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The risk factors for hepatic hydrothorax are unknown. METHODS We used data from three randomized trials of satavaptan treatment in patients with cirrhosis and ascites followed for up to 1 year. We excluded patients with previous hepatic hydrothorax or other causes for pleural effusion. The candidate risk factors were age, sex, heart rate, mean arterial pressure, diuretic-resistant ascites, a recurrent need for paracentesis, diabetes, hepatic encephalopathy, International Normalized Ratio, creatinine, bilirubin, albumin, sodium, platelet count, use of non-selective beta-blockers (NSBBs), spironolactone, furosemide, proton pump inhibitors, and insulin. We identified risk factors using a Fine and Gray regression model and backward selection. We reported subdistribution hazard ratios (sHR) for hepatic hydrothorax. Death without hepatic hydrothorax was a competing risk. RESULTS Our study included 942 patients, of whom 41 developed hepatic hydrothorax and 65 died without having developed it. A recurrent need for paracentesis (sHR: 2.55, 95% CI: 1.28-5.08), bilirubin (sHR: 1.18 per 10 µmol/l increase, 95% CI: 1.09-1.28), diabetes (sHR: 2.49, 95% CI: 1.30-4.77) and non-use of non-selective beta-blockers (sHR: 2.27, 95% CI: 1.13-4.53) were risk factors for hepatic hydrothorax. Development of hepatic hydrothorax was associated with a high mortality-hazard ratio of 4.35 (95% CI: 2.76-6.97). CONCLUSIONS In patients with cirrhosis and ascites, risk factors for hepatic hydrothorax were a recurrent need for paracentesis, a high bilirubin, diabetes and non-use of NSBBs. Among these patients with cirrhosis and ascites, development of hepatic hydrothorax increased mortality fourfold.
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Affiliation(s)
- Thomas Deleuran
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark. .,Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Hugh Watson
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.,Evotec ID, Lyon, France
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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17
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Baltaji S, Shojaee S. Indwelling Pleural Catheters for Refractory Hepatic Hydrothorax? A Call for Prospective Studies and Randomized Controlled Trials. J Bronchology Interv Pulmonol 2022; 29:161-163. [PMID: 35730776 DOI: 10.1097/lbr.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Stephanie Baltaji
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Allegheny Health Network, Pittsburg, PA
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA
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18
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Craciun R, Mocan T, Procopet B, Nemes A, Tefas C, Sparchez M, Mocan LP, Sparchez Z. Pulmonary complications of portal hypertension: The overlooked decompensation. World J Clin Cases 2022; 10:5531-5540. [PMID: 35979136 PMCID: PMC9258359 DOI: 10.12998/wjcc.v10.i17.5531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/22/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Rares Craciun
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Tudor Mocan
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Bogdan Procopet
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Andrada Nemes
- Intensiv Care Unit I, Cluj County Emergency Hosptial, Cluj-Napoca 400006, Romania
| | - Cristian Tefas
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Mihaela Sparchez
- 2nd Paediatric Clinic, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Please enter the state or province, Romania
| | - Lavinia-Patricia Mocan
- Department of Histology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400349, Romania
| | - Zeno Sparchez
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
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19
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Markatis E, Perlepe G, Afthinos A, Pagkratis K, Varsamas C, Chaini E, Papanikolaou IC, Gourgoulianis KI. Mortality Among Hospitalized Patients With Pleural Effusions. A Multicenter, Observational, Prospective Study. Front Med (Lausanne) 2022; 9:828783. [PMID: 35280903 PMCID: PMC8907663 DOI: 10.3389/fmed.2022.828783] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background Data regarding the prognostic significance of pleural effusion (PE) are scarce. Objective Explore the impact of PE on mortality among hospitalized patients. Methods Multicenter prospective observational study. Patients that underwent computed tomography (thorax and/or abdomen) and in which PE was detected, were admitted to the study. PE was classified by size on CT, anatomical distribution, diagnosis, and Light's criteria. Charlson comorbidity index (CCI), APACHE II, and SOFA score were calculated. Mortality at 1 month and 1 year were recorded. Results Five hundred and eight subjects, mean age 78 years. Overall mortality was 22.6% at 1 month and 49.4% at 1 year. Bilateral effusions were associated with higher mortality than unilateral effusions at 1 month (32 vs. 13.3%, p = 0.005) and large effusions with higher mortality than small effusions at 1 year (66.6 vs. 43.3%, p < 0.01). On multivariate analysis age, CCI, APACHE II, SOFA score, and bilateral distribution were associated with short-term mortality, while long-term significant predictors were CCI, APACHE II, SOFA, and malignant etiology. Exudates (excluding MPE) exhibited a survival benefit at both 1 month and 1 year but due to the smaller sample, fluid characteristics were not included in the multivariate analysis. Conclusions Pleural effusion is a marker of advanced disease. Mortality is higher within the first month in patients with PEs related to organ failure, while patients with MPE have the worst long-term outcome. Independent predictors of mortality, apart from CCI, APACHE II, and SOFA scores, are age and bilateral distribution in the short-term, and malignancy in the long-term.
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Affiliation(s)
- Eleftherios Markatis
- Pulmonary Department, Corfu General Hospital, Corfu, Greece
- *Correspondence: Eleftherios Markatis
| | - Garifallia Perlepe
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | | | | | - Charalampos Varsamas
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, Larissa, Greece
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20
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Rendón-Ramírez EJ, González-Villarreal M, Muñoz-Espinoza LE, Colunga-Pedraza PR, Moreno JF, Salinas-Chapa M, Mercado-Longoria R, Treviño-García KB, Cazares-Rendón E, Porcel JM. Pleural Effusions Identified by Point-of-Care Ultrasound Predict Poor Outcomes in Decompensated Cirrhosis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3283-3290. [PMID: 34366186 DOI: 10.1016/j.ultrasmedbio.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 06/13/2023]
Abstract
Chronic liver disease (CLD) may be associated with pleural effusions (PEs). This article prospectively evaluates whether detection of PEs on thoracic ultrasound (TUS) at the bedside independently predicts mortality and length of stay (LOS) in hospitalized patients with a decompensated CLD. A total of 116 consecutive inpatients with decompensated cirrhosis underwent antero-posterior chest radiographs (CXR) and TUS to detect PEs. Their median age was 54 y (interquartile range, 47-62), 90 (70.6%) were male, and 61 (52.6%) fell into the Child-Pugh class C categorization. TUS identified PEs in 58 (50%) patients, half of which were small enough to preclude thoracentesis. CXR failed to recognize approximately 40% of PEs seen on TUS. The identification of PEs by TUS was associated with a longer LOS (10 vs. 5.5 d, p < 0.001) and double mortality (39.7% vs. 20.7%, p = 0.021). In multivariate analysis, PEs were independently related to poor survival (hazard ratio 2.08, 95% confidence interval [CI] 1.02-4.25; p = 0.044). Patients with both Child-Pugh C stage and PEs had the lowest survival rate (70 vs. 317 d, p = 0.001). In conclusion, PEs identified by TUS in hospitalized patients with decompensated CLD independently predict a poor outcome and portend a longer LOS.
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Affiliation(s)
- Erick Joel Rendón-Ramírez
- Pulmonary and Critical Care Medicine Service, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Marusia González-Villarreal
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Linda Elsa Muñoz-Espinoza
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Perla Rocío Colunga-Pedraza
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Juan Francisco Moreno
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Matias Salinas-Chapa
- Radiology Department, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Roberto Mercado-Longoria
- Pulmonary and Critical Care Medicine Service, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Karla Belén Treviño-García
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Erika Cazares-Rendón
- Facultad de Medicina, Valle de las Palmas, Universidad Autónoma de Baja California, Mexico
| | - José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain.
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21
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Matei D, Craciun R, Crisan D, Procopet B, Mocan T, Pasca S, Zaharie R, Popovici B, Sparchez Z. Hepatic Hydrothorax-An Independent Decompensating Event Associated with Long-Term Mortality in Patients with Cirrhosis. J Clin Med 2021; 10:3688. [PMID: 34441984 PMCID: PMC8396982 DOI: 10.3390/jcm10163688] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Background: Hepatic hydrothorax (HH) is an understudied complication of decompensated cirrhosis. We aimed to evaluate the long-term prognosis of patients with HH by comparing them with a matched non-HH group. Methods: This retrospective study included 763 consecutive patients hospitalized for decompensated cirrhosis and ascites. Ninety-seven patients with HH were matched for survival analysis with non-HH patients based on liver disease severity. Results: The prevalence of HH was 13.1%. Patients with HH had significantly worse overall liver function. Upon matching, patients with HH had a lower long-term survival (15.4% vs. 30.9% at 5 years) with a mean overall survival of 22.2 ± 2.2 months for the HH group vs. 27.1 ± 2.6 months for the non-HH group (Log Rank-0.05). On multivariate survival analysis using Cox regression, the MELD-Na score, ALBI grade, hepato-renal syndrome, and grade III ascites had a significant impact on mortality in patients with HH. In patients with HH, a MELD-Na score ≥ 16, ALBI grade III, hepato-renal syndrome, or severe ascites delineated high-mortality risk groups. Conclusions: HH is consistently associated with more advanced liver disease. Patients with HH have worse long-term survival, their prognosis being closely intertwined with overlapping decompensating events.
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Affiliation(s)
- Daniela Matei
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Rares Craciun
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Dana Crisan
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Department of Gastroenterology, Cluj-Napoca Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Bogdan Procopet
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Tudor Mocan
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Sergiu Pasca
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
| | - Roxana Zaharie
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Bogdan Popovici
- Department of Thoracic Surgery, “Leon Daniello” Pulmonology Hospital, 400371 Cluj-Napoca, Romania;
| | - Zeno Sparchez
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
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22
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Gilbert CR, Shojaee S, Maldonado F, Yarmus LB, Bedawi E, Feller-Kopman D, Rahman NM, Akulian JA, Gorden JA. Pleural Interventions in the Management of Hepatic Hydrothorax. Chest 2021; 161:276-283. [PMID: 34390708 DOI: 10.1016/j.chest.2021.08.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023] Open
Abstract
Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.
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Affiliation(s)
- Christopher R Gilbert
- Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA.
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Eihab Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jason A Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jed A Gorden
- Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
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23
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Hou YY, Peng L, Zhou M. Meigs syndrome with pleural effusion as initial manifestation: A case report. World J Clin Cases 2021; 9:5972-5979. [PMID: 34368316 PMCID: PMC8316948 DOI: 10.12998/wjcc.v9.i21.5972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Meigs syndrome is a rare neoplastic disease characterized by the triad of benign solid ovarian tumor, ascites, and pleural effusion. In postmenopausal women with pleural effusions, ascites, elevated CA-125 level, and pelvic masses, the probability of disseminated disease is high. Nevertheless, the final diagnosis is based on its histopathologic features following surgical removal of a mass lesion. Here we describe a case of Meigs syndrome with pleural effusion as the initial manifestation.
CASE SUMMARY A 52-year-old woman presented with a 2-mo history of dry cough and oppression in the chest and was admitted to our hospital due to recurrent pleural effusion and gradual worsening of dyspnea that had occurred over the previous month. Two months before admission, the patient underwent repeated chest drainage and empirical anti-tuberculosis treatment. However, the pleural fluid accumulation persisted, and the patient began to experience dyspnea on exertion leading to admission. A computed tomography scan of the chest, abdominal ultrasound, and magnetic resonance imaging confirmed the presence of right-sided pleural effusion and ascites with a right ovarian mass. Serum tumor markers showed raised CA-125. With a suspicion of a malignant tumor, the patient underwent laparoscopic excision of the ovarian mass and the final pathology was consistent with an ovarian fibrothecoma. On the seventh day postoperation, the patient had resolution of the right-sided pleural effusion.
CONCLUSION Despite the relatively high risk of malignancy when an ovarian mass associated with hydrothorax is found in a patient with elevated serum levels of CA-125, clinicians should be aware about rare benign syndromes, like Meigs, for which surgery remains the preferred treatment.
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Affiliation(s)
- Ya-Ya Hou
- Department of Obstetrics and Gynaecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Li Peng
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Mei Zhou
- Department of Respiratory Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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24
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Ingviya T, Wasuwanich P, Scheimann AO, Felix G, Laengvejkal P, Vasilescu A, Imteyaz H, Seaberg EC, Karnsakul W. Clinical Predictors of Morbidity and Mortality in Hospitalized Pediatric Patients With Ascites. J Pediatr Gastroenterol Nutr 2021; 73:86-92. [PMID: 33633084 DOI: 10.1097/mpg.0000000000003104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Ascites is a pathologic buildup of fluid in the peritoneal cavity. Knowledge is lacking in clinical outcome in pediatric patients with ascites. We aim to identify and assess clinical variables, associated with morbidity and mortality in pediatric patients who are hospitalized with ascites. METHODS A retrospective cohort study was performed on patients ages 0 to 21 hospitalized at Johns Hopkins Hospital between 1983 and 2010 with an ICD-9 discharge diagnosis of ascites (789.5, 789.51, 789.59). A total of 518 pediatric patients were studied, all with a diagnosis of ascites during hospitalization. Study outcomes included hospital length of stay (LOS) as a proxy for morbidity and death at hospital discharge for mortality. Variables analyzed included demographic data, ascites etiology and grade, comorbidities, and laboratory markers. Variables were analyzed by log-linear regression and competing risk model. RESULTS Among the 3 age groups (0-5, 6-12, and 13-21), the 0 to 5 age group experienced significantly increased LOS (P < 0.001) and mortality (P = 0.027). Ascites etiology of veno-occlusive disease (VOD) and the presence of hydrothorax or thrombocytopenia was also significantly associated with increased LOS. Ascites with the etiology of congestive hepatopathy and the presence of grade 3 ascites, hepatic encephalopathy, hepatorenal syndrome, hydrothorax, hyponatremia, and thrombocytopenia were associated with increased mortality. Additionally, black pediatric patients have an increased risk of mortality (P = 0.027). Other factors including sex, leukopenia, portal vein thrombosis, and splenomegaly were not associated with LOS or mortality. CONCLUSIONS Morbidity and mortality in pediatric patients hospitalized with ascites are associated with specific demographic and clinical factors. Further studies are required to apply this knowledge to predict the clinical outcomes.
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Affiliation(s)
- Thammasin Ingviya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Medical Data Center for Research and Innovation
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Paul Wasuwanich
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN
| | - Ann O Scheimann
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Grace Felix
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pavis Laengvejkal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Vasilescu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hejab Imteyaz
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric C Seaberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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25
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Banini BA, Alwatari Y, Stovall M, Ogden N, Gershman E, Shah RD, Strife BJ, Shojaee S, Sterling RK. Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology 2020; 72:1851-1863. [PMID: 32585037 DOI: 10.1002/hep.31434] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Bubu A Banini
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yahya Alwatari
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Madeline Stovall
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Nathan Ogden
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Evgeni Gershman
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Brian J Strife
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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