How to manage hepatic hydrothorax with a Model for End-Stage Liver Disease (MELD) score of 28 and hypoalbuminemia for large volume thoracentesis?

From the Guidelines

Management of hepatic hydrothorax in a patient with advanced liver disease (MELD 28) should prioritize liver transplant evaluation as the definitive treatment, given the high MELD score.

Initial Management

• Sodium restriction (2g/day) and diuretic therapy with spironolactone (100-400 mg/day) and furosemide (40-160 mg/day) should be initiated, titrating doses to achieve negative fluid balance while monitoring electrolytes and renal function 1.
• For symptomatic relief, therapeutic thoracentesis is recommended, with administration of intravenous albumin (6-8g per liter of fluid removed) when removing large volumes (>1.5 liters) to prevent post-procedure complications like hypotension and renal dysfunction 1.

Considerations for TIPS Placement

• For refractory cases, consider transjugular intrahepatic portosystemic shunt (TIPS) placement if the patient is a candidate, though this carries risks of hepatic encephalopathy and liver failure 1.
• However, given the high MELD score (28), TIPS placement may be associated with a poorer outcome, and the decision should be made on a case-by-case basis, taking into account the patient's overall clinical condition and potential benefits and risks 1.

Additional Considerations

• Indwelling pleural catheters may provide palliative relief in non-TIPS candidates 1.
• Throughout management, monitor for spontaneous bacterial empyema with pleural fluid analysis when clinically indicated, and consider antibiotic prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole in high-risk patients 1.
• The most recent and highest quality study on the management of hepatic hydrothorax is from 2024, which highlights the importance of individualized treatment approaches and careful consideration of the risks and benefits of TIPS placement 1.

From the FDA Drug Label

Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume. The management of hepatic hydrothorax with large volume thoracentesis in a patient with a MELD score of 28 and low albumin may require the use of albumin infusion to support the blood volume and prevent hypovolemic shock.

• The use of albumin infusion is indicated in patients with cirrhosis who undergo removal of ascitic fluid, which can cause changes in cardiovascular function and lead to hypovolemic shock.
• In such cases, albumin infusion may be required to support the blood volume 2.
• The dosage and administration of albumin should be guided by the patient's individual needs and hemodynamic response.

From the Research

Management of Hepatic Hydrothorax

• The management of hepatic hydrothorax is difficult and typically involves a low-salt diet plus diuretics, with the best diuretic regimen being a combination of furosemide and spironolactone 3.
• However, about 25% of patients are refractory to this regimen, and additional therapy is indicated 3.
• Thoracentesis is a common procedure used to manage hepatic hydrothorax, and in some cases, a pigtail catheter may be placed to drain large volumes of fluid 3.
• Other treatment options include transjugular intrahepatic portosystemic shunt (TIPS) and liver transplant, which have been shown to improve outcomes in patients with hepatic hydrothorax 4.

MELD Score and Hepatic Hydrothorax

• The Model for End-Stage Liver Disease (MELD) score is used to evaluate the severity of liver disease, and patients with hepatic hydrothorax tend to have higher MELD scores 4, 5.
• A MELD score of 28 is considered high and indicates severe liver disease 5.
• Receiving MELD exception points for hepatic hydrothorax has been shown to be associated with a significant reduction in posttransplant mortality 6.

Albumin and Large Volume Thoracentesis

• Serum albumin levels are often low in patients with hepatic hydrothorax, and this can be a useful marker for diagnosis and management 5.
• Large volume thoracentesis is a common procedure used to manage hepatic hydrothorax, and it is often performed in patients with low serum albumin levels 3, 4.
• The serum to pleural fluid albumin gradient (SPAG) is a useful criterion for diagnosis of hepatic hydrothorax, and it can help differentiate hepatic hydrothorax from other causes of pleural effusion 4.