Is a PleurX (pleural catheter) appropriate therapy for hepatic hydrothorax?

From the Guidelines

A PleurX catheter can be considered as a treatment option for hepatic hydrothorax in select patients who have refractory effusions despite optimal medical management, but it should be used with caution due to potential complications, as recommended by the most recent guidance from the American Association for the Study of Liver Diseases 1 and the European Respiratory Journal 1.

Key Considerations

• The primary treatment for hepatic hydrothorax involves dietary sodium restriction and diuretics, with thoracentesis as required 1.
• Refractory or recurrent hepatic hydrothorax is best treated with TIPS or liver transplantation (LT) 1.
• Indwelling pleural catheters, such as PleurX, may be considered in carefully selected patients who do not respond to medical therapy and are not candidates for TIPS or LT 1.

Management and Risks

• The use of PleurX catheters in patients with hepatic hydrothorax requires careful consideration of the risks, including infection, protein loss, electrolyte imbalances, and potential kidney injury 1.
• Patients should first undergo optimization of medical therapy, including sodium restriction, diuretics, and management of underlying portal hypertension, before considering a PleurX catheter 1.
• The decision to place a PleurX catheter should be made as part of a multidisciplinary approach, involving hepatology, pulmonology, and thoracic surgery, with careful consideration of the patient's transplant candidacy, overall prognosis, and quality of life goals 1.

Treatment Approach

• The typical management of PleurX catheters involves draining 500-1000 mL every 1-2 days as needed for symptoms, with adjustments based on individual patient response.
• Patients with hepatic hydrothorax should be considered for liver transplantation, as it is the only curative treatment for the condition 1.

From the Research

PleurX Catheter for Hepatic Hydrothorax

• A PleurX catheter is a type of tunneled pleural catheter that can be used for the management of refractory hepatic hydrothorax, as shown in a case study from 2.
• The use of indwelling pleural catheters, such as PleurX, has been proposed as a novel treatment option for hepatic hydrothorax, with studies indicating its potential effectiveness in managing symptoms and reducing pleural effusion volumes 3, 4.

Efficacy and Safety

• A retrospective review of patients who underwent IPC placement for hepatic hydrothorax found that complications occurred in 36% of patients, with empyema being the most common complication 3.
• A meta-analysis of the use of indwelling tunneled pleural catheters for nonmalignant pleural effusions, including hepatic hydrothorax, demonstrated a rate of spontaneous pleurodesis of 51% 4.
• A small, prospective study found spontaneous pleurodesis rates of 33% and an infection rate of 16.7% in patients with ITPC placed for hepatic hydrothorax 4.

Comparison to Other Treatments

• Transjugular intrahepatic portosystemic shunt (TIPS) placement has been shown to be a safe and effective temporizing treatment for carefully selected patients with refractory hepatic hydrothorax, but patient survival is limited and primarily determined by availability of liver transplantation 5, 6.
• The use of PleurX catheters may be an acceptable treatment option for patients with hepatic hydrothorax who are refractory to conventional medical management, but larger, randomized controlled trials are needed to further evaluate their safety and efficacy 4.