Hepatic hydrothorax as a manifestation of decompensated cirrhosis: An update on current management and future directions

Table 1 Biochemical profiles of transudative vs exudative pleural aspirates

	Transudate	Exudate
Pleural: Serum protein	< 0.5 g/dL	> 0.5 g/dL
Pleural: Serum LDH	< 0.6 g/dL	> 0.6 g/dL
Pleural fluid LDH	< 2/3 ULN serum LDH	> 2/3 ULN serum LDH
Pleural: Serum albumin1	< 0.6 g/dL	> 0.6 g/dL

¹Adjunct criteria proposed by Bielsa et al[18].

Light’s criteria, as adapted from the British Thoracic Guideline for Thoracic Disease[19]. Pleural fluid is considered an exudate if at least one of the above criteria is met. LDH: Lactate dehydrogenase; ULN: Upper limit of normal.

Table 2 Summary of key studies reporting on treatment outcomes relevant to hepatic hydrothorax

Ref.	Sample size (n)	Age (years)	Sex (male/female)	Hepatic function	Summary of key outcomes
Badillo and Rockey[1], 2014	77	52 ± 9	49/28	MELD: 16 ± 9. Child-Pugh: 2/37/35	83% managed with diuretics/thoracentesis, 10% TIPS, 7% underwent liver transplantation. TIPS prolonged survival from 368 days to 845 days
Liu et al[7], 2010	52	62.2 ± 12.6	23/29	Child-Pugh: 4/20/28	50% of patients undergoing surgical repair and/or pleurodesis achieved resolution of HH. Median survival of patients with successful intervention was 22.5 months
Chen et al[20], 2016	24	59.8 ± 8.5	NA	MELD: 19.4 ± NA	No patient required further pleural drainage procedures post-IPC placement. Pleural fluid infection in 16.7%
Romero et al[27], 2022	84	58.3 ± 11.5	46/38	MELD: 26.8 ± 7.1	Overall and transplant-free survival at 12 months were 68% and 41%, respectively. Current smoking and acute kidney injury increased mortality
Young et al[28], 2019	147 (32 with HH)	56.1 ± 9.7	97/50	MELD: 15.2 ± 4.4. Child-Pugh: 9.4 ± 1.2	No difference in overall response or survival rates post-TIPS in refractory HH vs refractory ascites
Orman and Lok[29], 2009	17	55 ± 9.4	7/10	MELD: 16 ± 7.1	16/17 patients had a complication due to chest tube placement and 3-month mortality was 35%
Liu et al[30], 2004	59 (24 with HH)	53.8 ± 11.2	31/28	Child-Pugh: 3/31/25	47/59 patients had ≥ 1 complication due to chest tube placement and mortality was 25.4%
Kniese et al[31], 2019	62	60.7 ± 10.8	34/28	MELD-Na: 24 ± 6.5	36% had a complication due to IPCs and 10/62 were transplanted successfully post-IPC
Shojaee et al[32], 2019	79	60 ± 10.7	43/36	MELD: 18.1 ± 5.1	10% pleural space infection risk and 2.5% mortality post-IPC. Older age is a predictor of post-IPC mortality
Huang et al[33], 2016	63	60.4 ± 15	32/31	MELD: 14.6 ± 5.1. Child-Pugh: 12/36/15	4/63 patients experienced recurrence after VATS and 1-month mortality was 9.5%. Renal dysfunction and higher MELD predicted 3-month mortality
Luh and Chen[34], 2009	12	NA	NA	NA	4/12 had HH recurrence and massive ascites despite VATS. 6/12 died of end-stage liver-disease (including 4 patients with favourable early post-operative course) by 23 months
Lee et al[35], 2011	11	63 (38-84)	6/5	MELD: 16 (9-21). Child-Pugh: 0/2/9	Successful chemical pleurodesis in 72.7% and remained HH-free for a median of 16 weeks. 10/11 had AEs and 5/11 had procedure-related mortality
Bellot et al[36], 2013	40 (0 with HH)	59 (34-80)	28/12	MELD: 12.6 ± 4. Child-Pugh: 0/30/10	ALFApump® reduced median LVP per month. Main AEs: Liver-related (75%), infections (100%), catheter dislodgement (12.5%)
Bureau et al[37], 2020	58 (0 with HH)	61.9	46/12	MELD: 11.7 ± NA	ALFApump® group did not require LVP in first 6 months. Serious AEs were more common with ALFApump® vs LVP (85.2% vs 45.2%)
Hannah et al[38], 2023	24 (0 with HH)	59.5 (53.3-63.3)	17/7	MELD: 14.5 (11.3-18). Child-Pugh: 1/12/11	Albumin infusions associated with reduced hospital admission and paracentesis requirement
Gow et al[39], 2022	23 (2 with HH)	59.6 (42.5-68.6)	23/0	MELD: 22.5 (14-41). Child-Pugh: 10 (8-13)	Significant reduction in MELD score and median LVP/thoracentesis requirement with continuous terlipressin infusion. No serious AEs reported

Reported as mean ± SD, median (interquartile range), or median (range). Child-Pugh reported as classes A/B/C or as numerical scores. AEs: Adverse events; ALFApump^®: Automated low-flow ascites pump; HH: Hepatic hydrothorax; IPC: Indwelling pleural catheter; LVP: Large-volume paracentesis; MELD: Model for end-stage liver disease; NA: Not available; TIPS: Transjugular intrahepatic portosystemic shunt; VATS: Video-assisted thoracoscopic surgery.

Table 3 Summary of outcomes from published studies on video-assisted thoracoscopic surgery

Ref.	Study population (n, intervention)	Resolution rate	Mortality post-VATS
Huang et al[33], 2016	63, VATS only	At median 20.5 months: 93.7%	At 3 months: 25.4%
Luh and Chen[34], 2009	12, VATS ± pleurodesis	At 36 months: 33.3%	At 23 months: 50%
Ikeda et al[50], 2021	1, VATS only	100%1	NA
Nakamura et al[51], 2012	1, VATS only	100%1	NA
Ibi et al[52], 2008	2, VATS ± pleurodesis	100%2	Case 1 NA; case 2 0% at 1 year

¹Follow-up period not reported by studies.

²Follow-up period not reported for case 1 whereas the follow-up period for case 2 was one year.

NA: Not available; VATS: Video-assisted thoracoscopic surgery.