From the Guidelines
Management of hepatic hydrothorax in a patient with MELD score 28 requires an aggressive approach due to the advanced liver disease, with initial management focusing on sodium restriction and diuretic therapy, and consideration of liver transplantation as the definitive treatment. The patient should be started on sodium restriction (2g/day) and diuretic therapy with spironolactone (starting at 100mg daily) and furosemide (starting at 40mg daily), titrating up as needed while monitoring electrolytes and renal function 1. Therapeutic thoracentesis is recommended for symptomatic relief of dyspnea, but should be limited due to risks of protein loss and infection 1. For refractory cases, consider transjugular intrahepatic portosystemic shunt (TIPS) placement, though this carries higher risks with MELD 28 1. Indwelling pleural catheters may provide palliative relief in selected patients. Chest tube placement should be avoided due to high complication rates. Given the high MELD score, the patient should be evaluated for liver transplantation as the definitive treatment, as hepatic hydrothorax indicates decompensated cirrhosis with poor prognosis 1. Antibiotics should be administered if spontaneous bacterial empyema is suspected. Albumin infusion (1g/kg) may be considered with large-volume thoracentesis to prevent post-procedure hypotension and renal dysfunction. Regular monitoring of respiratory status, electrolytes, and renal function is essential throughout treatment.
Some key points to consider in the management of hepatic hydrothorax include:
- The importance of sodium restriction and diuretic therapy in the initial management of hepatic hydrothorax 1
- The role of therapeutic thoracentesis in providing symptomatic relief of dyspnea, while minimizing the risks of protein loss and infection 1
- The consideration of TIPS placement in refractory cases, despite the higher risks associated with MELD 28 1
- The potential benefits and risks of indwelling pleural catheters in selected patients
- The importance of evaluating the patient for liver transplantation as the definitive treatment, given the poor prognosis associated with hepatic hydrothorax and high MELD score 1
Overall, the management of hepatic hydrothorax in a patient with MELD score 28 requires a comprehensive and aggressive approach, with consideration of the patient's underlying liver disease and potential complications.
From the Research
Management of Hepatic Hydrothorax
- The management of hepatic hydrothorax involves a stepwise approach, including reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis, and liver transplantation 2.
- Diuretics and/or thoracentesis are commonly used to manage hepatic hydrothorax, with transjugular intrahepatic portosystemic shunt (TIPS) and liver transplant being considered in more severe cases 3.
- The use of indwelling pleural catheters has also been discussed as a treatment option, with available data and management recommendations being considered 4.
Treatment Options for Hepatic Hydrothorax with MELD 28
- For patients with a high MELD score, such as 28, liver transplantation is considered the definitive treatment option 3, 5.
- TIPS can also be considered as a treatment option, with a study showing that patients who underwent TIPS had an average time from presentation to death of 845 days, compared to 368 days for all patients 3.
- Other treatment options, such as diuretics, thoracentesis, and pleurodesis, may also be considered, but the effectiveness of these treatments may be limited in patients with a high MELD score.