In a patient with cirrhosis who develops a right‑sided pleural effusion (hepatic hydrothorax), how should it be evaluated and managed?

Management of Pleural Effusion in Cirrhosis

First-line management of hepatic hydrothorax consists of dietary sodium restriction and diuretics, with therapeutic thoracentesis performed as needed for symptomatic relief, while simultaneously evaluating all patients for liver transplantation given the 74% mortality at 90 days. 1

Initial Diagnostic Evaluation

Confirm Hepatic Hydrothorax

• Perform diagnostic thoracentesis immediately to analyze pleural fluid characteristics and exclude alternative diagnoses, particularly infection, malignancy, or cardiopulmonary causes 1
• Calculate the serum-to-pleural fluid albumin gradient: a gradient >1.1 g/dL confirms hepatic hydrothorax and indicates portal hypertension as the underlying cause 1, 2
• If the gradient is ≤1.1 g/dL, or if the effusion is left-sided, or if ascites is absent, strongly suspect alternative diagnoses including malignancy, infection, pancreatitis, or cardiac disease 1, 2
• Measure pleural fluid cell count with differential, protein, LDH, and send for culture in blood culture bottles (positive in 75% of spontaneous bacterial empyema cases) 2

Critical Diagnostic Pitfall

• 9% of patients with hepatic hydrothorax have no clinically apparent ascites, making diagnosis challenging when abdominal fluid is not obvious 1, 2
• The effusion is right-sided in 73% of cases, left-sided in 17%, and bilateral in 10% 1

Exclude Spontaneous Bacterial Empyema

• Spontaneous bacterial empyema (SBE) must be ruled out in every cirrhotic patient with pleural effusion, as it occurs in up to 50% of cases 2
• SBE is diagnosed when pleural fluid absolute neutrophil count exceeds 250/mm³ 2, 3
• If SBE is confirmed, administer albumin 1.5 g/kg IV on day 1 and 1.0 g/kg IV on day 3 along with antibiotics, particularly in patients with renal dysfunction or severe hepatic decompensation 3

Prognostic Considerations

Hepatic hydrothorax carries an exceptionally poor prognosis that exceeds predictions based on MELD score alone. 1

• Mortality at 90 days is 74% despite a mean MELD score of only 14, which would otherwise predict 6-8% mortality 1
• Median survival ranges from 8-12 months after diagnosis 1
• Common prognostic scores like Child-Pugh and MELD significantly underestimate the adverse outcomes in these patients 1

First-Line Medical Management

Sodium Restriction and Diuretics

• Initiate dietary sodium restriction (typically <2 g/day) combined with diuretics as the cornerstone of initial therapy 1
• Management mirrors that of ascites, as the pleural fluid originates from peritoneal cavity through diaphragmatic defects driven by negative intrathoracic pressure during inspiration 1, 4
• Continue diuretics and salt restriction even after definitive procedures until complete resolution of fluid 1

Therapeutic Thoracentesis

• Perform therapeutic thoracentesis to relieve dyspnea when patients are symptomatic 1
• Thoracentesis can be performed without transfusion of platelets or plasma despite coagulopathy commonly present in cirrhosis 1
• No data exist to guide the upper limit of pleural fluid volume that can be safely removed 1
• Fluid reaccumulates rapidly after thoracentesis due to ongoing passage through diaphragmatic defects, necessitating repeated procedures 1, 4

Large Volume Paracentesis

• If ascites is present, large volume paracentesis (LVP) with IV albumin may improve ventilatory function, but thoracentesis is generally still required 1

Management of Refractory Hepatic Hydrothorax

Refractory or recurrent hepatic hydrothorax is best treated with TIPS or liver transplantation. 1

TIPS (Transjugular Intrahepatic Portosystemic Shunt)

• TIPS should be considered as second-line treatment for refractory hepatic hydrothorax in carefully selected patients 1
• TIPS achieves complete response in approximately 56% of cases and can serve as definitive treatment or bridge to transplantation 1, 4
• Use small-diameter PTFE-covered stents to reduce risk of TIPS dysfunction and hepatic encephalopathy 1

TIPS Contraindications

TIPS is not recommended in patients with: 1

• Serum bilirubin >3 mg/dL
• Platelet count <75 × 10⁹/L
• Current hepatic encephalopathy grade ≥2 or chronic hepatic encephalopathy
• Active infection
• Progressive renal failure
• Severe systolic or diastolic dysfunction
• Pulmonary hypertension

Liver Transplantation

• All patients with hepatic hydrothorax should be evaluated for liver transplantation given the exceptionally poor prognosis 1
• Additional priority for liver transplantation is granted for patients with hepatic hydrothorax meeting defined criteria 1
• Liver transplantation represents the only definitive curative therapy 1, 5, 6

Procedures to AVOID

Chest Tube Insertion

• Chest tube insertion for hepatic hydrothorax should be avoided due to high complication rates including protein depletion, malnutrition, pleural infection, and septic shock 1, 7
• In one series, 3 of 8 patients (37.5%) died from septic shock caused by pleural infection after chest tube drainage 7

Chemical Pleurodesis

• Chemical pleurodesis is not recommended as it often leads to loculated collections 1
• While the pooled rate of complete response after pleurodesis is 72%, the pooled rate of complications is as high as 82% 1
• Pleurodesis may only be considered in patients who are not candidates for TIPS or liver transplantation 1

Alternative Options for Select Patients

Indwelling Tunneled Pleural Catheters

• Indwelling tunneled pleural catheters may be considered in carefully selected patients who do not respond to medical therapy and are not candidates for TIPS or transplantation 1, 8
• These patients are at risk for protein depletion and malnutrition with chronic drainage 1
• For patients with refractory hepatic hydrothorax who are not transplant candidates, indwelling pleural catheters should be managed with palliative intent 8

Serial Thoracentesis

• For transplant candidates or those with unclear hepatology treatment plans, serial thoracentesis is often the standard treatment while awaiting more definitive therapy 8

Key Clinical Pitfalls to Avoid

• Do NOT target serum albumin levels with albumin infusions outside the specific indication of SBE, as a 2024 trial showed targeting albumin levels of 3 g/dL resulted in significantly higher rates of pulmonary edema and fluid overload without benefit 3
• Do NOT place chest tubes for chronic drainage given the exceptionally high complication rates 1, 7
• Do NOT delay transplant evaluation based on MELD score alone, as hepatic hydrothorax mortality far exceeds MELD predictions 1
• Do NOT assume absence of ascites excludes hepatic hydrothorax, as 9% of cases occur without clinically apparent ascites 1, 2