Can liver failure cause pleural effusion?

From the Guidelines

Yes, liver failure can cause pleural effusion, as evidenced by the development of hepatic hydrothorax in approximately 5-12% of patients with advanced liver disease. This condition occurs due to several mechanisms related to the liver's compromised function, including decreased albumin production leading to lower oncotic pressure in blood vessels, allowing fluid to leak into the pleural space 1. Additionally, portal hypertension from liver failure can cause ascites (abdominal fluid), which may cross the diaphragm through small defects and accumulate in the pleural cavity, creating what's known as hepatic hydrothorax.

The management of hepatic hydrothorax involves controlling ascites with diuretics and/or large-volume paracentesis (LVP), as well as therapeutic thoracentesis to provide symptomatic relief from dyspnea 1. However, repeated thoracentesis procedures increase the risks of complications, including pneumothorax, bleeding, and pleural infection. In patients with refractory hydrothorax, transjugular intrahepatic portosystemic shunt (TIPSS) insertion has been suggested as a definitive treatment or as a bridge to transplantation, with a reported response rate of 56% 1.

According to the most recent guidelines, the first-line management of hepatic hydrothorax should focus on treating the underlying liver disease while addressing symptoms through sodium restriction, diuretics like spironolactone and furosemide, and in severe cases, therapeutic thoracentesis or TIPSS placement 1. It is essential to note that the causes of pleural effusion are varied, and establishing the characteristics of the pleural fluid is crucial in the diagnostic approach, with more than 80% of transudates being due to heart failure, followed by liver cirrhosis (10%), hypoalbuminemia, nephrotic syndrome, and atelectasis 1.

In terms of specific management strategies, the use of diuretics and thoracentesis is recommended as the first-line management of hepatic hydrothorax, with TIPSS insertion considered in selected patients with recurrent symptomatic hepatic hydrothorax 1. Overall, the management of liver failure-related pleural effusion requires a comprehensive approach, taking into account the underlying liver disease, the presence of ascites, and the severity of symptoms.

Key points to consider in the management of liver failure-related pleural effusion include:

• Controlling ascites with diuretics and/or LVP
• Therapeutic thoracentesis for symptomatic relief
• Consideration of TIPSS insertion in patients with refractory hydrothorax
• Sodium restriction and diuretics like spironolactone and furosemide for symptom management
• Evaluation for liver transplantation in eligible patients 1.

From the Research

Liver Failure and Pleural Effusion

• Liver failure, particularly in patients with cirrhosis, can lead to pleural effusion, a condition characterized by the accumulation of fluid in the pleural space surrounding the lungs 2, 3, 4, 5.
• The pathophysiology of pleural effusion in liver disease involves the movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects, a process known as hepatic hydrothorax 3, 5.
• Studies have shown that pleural effusion is a common complication of chronic liver disease, with an estimated prevalence of 5-6% in patients with liver cirrhosis 5.
• The diagnosis of pleural effusion in liver disease typically involves thoracentesis and pleural fluid analysis, with initial management consisting of sodium restriction, diuretics, and therapeutic thoracentesis 5.

Clinical Manifestations and Outcomes

• Pleural effusion in liver disease can lead to significant clinical manifestations, including shortness of breath, hypotension, and spontaneous bacterial empyema, a potentially life-threatening infection 3, 5.
• The presence of pleural effusion has been shown to predict poor outcomes in patients with decompensated cirrhosis, including longer length of stay and increased mortality 6.
• Patients with both Child-Pugh C stage and pleural effusion have been found to have the lowest survival rate, highlighting the importance of early detection and management of pleural effusion in liver disease 6.

Management and Treatment

• Treatment options for pleural effusion in liver disease include talc pleurodesis, video-assisted thoracoscopy, and transjugular intrahepatic portosystemic shunt, with the goal of reducing fluid accumulation and preventing recurrence 4, 5.
• Repeated talc injection through the drain may be useful for patients in poor clinical status, and intrahepatic porto-systemic shunt may provide a bridge prior to liver transplantation 4.