Natural history and outcomes of patients with liver cirrhosis complicated by hepatic hydrothorax.

Abstract

Background and Aims: Hepatic hydrothorax (HH) is an uncommon and difficult-to-manage complication of cirrhosis with no established clinical guidelines. We sought to define the clinical outcomes of patients presenting with HH managed with current standards-of-care. Method(s): International Classification of Diseases-10 codes identified cirrhotic patients with HH presenting to 3 tertiary centres (Melbourne, Australia) from 2010 to 2018. HH was defined as pleural effusion in the absence of cardiopulmonary disease. Medical records were reviewed to determine baseline characteristics and survival. Primary outcome was 12-month mortality. The Kaplan-Meier method was used to calculate survival probability. Result(s): 83 patients were included. Median age was 59 years (IQR 54-63), 57% were male and median MELD score was 29 (IQR 25-33). Common causes of cirrhosis were viral (33%), alcohol (27%) and nonalcoholic fatty liver disease (19%); 29% had hepatocellular carcinoma. Pleural effusions were typically right-sided (83%) and 73% had concurrent ascites. There were 169 hospital admissions for HH over the study period. Median length of stay was 11 days and 22% required intensive care unit admission. 89% and 7% patients were prescribed diuretics and non-selective beta-blockers respectively at presentation. Diuretic therapy alone was commenced in 13 (8%) presentations while 120 (71%) received diuresis and pleurocentesis (median 3L drained); 17% required blood products to facilitate pleurocentesis. 23 patients received intercostal drain insertion, 1 pleurodesis and 10 proceeded to transjugular intrahepatic portosystemic shunt insertion. 31 (37%) patients underwent liver transplantation (OLT). Significant complications were observed in 45% of admissions, including: infection [n = 25], hepatic encephalopathy [n = 19] and pneumothorax [n = 11]. 86% patients required re-admission within 6-months of index admission. The 12-month mortality rate was 29% (n = 24) and probability of transplant-free survival was 42% and 36% at 12- and 24-months respectively (Figure). All patients receiving OLT survived to 12-months. Conclusion(s): Patients with decompensated cirrhosis and HH are a challenging population with a poor 12-month survival despite current treatments. Transplant assessment should be considered in all cases. There is a high prevalence of in-hospital and procedure-related complications and a minority of patients experience disease control with diuretic therapy alone.Copyright © 2020 European Association for the Study of the Liver