Liver and Bile
Hepatology. 2024;79(4):844–56
Refractory hepatic hydrothorax is associated with increased mortality with death occurring at lower MELD-Na compared to cirrhosis and refractory ascites
Background and aims: Although refractory hepatic hydrothorax (RH) is a serious complication of cirrhosis, waitlisted patients do not receive standardized Model for End-stage Liver Disease (MELD) exemption because of inadequate evidence suggesting mortality above biochemical MELD. This study aimed to examine liver-related death (LRD) associated with RH compared to refractory ascites (RA).
Approach and results: This was a retrospective cohort study of Veterans with cirrhosis. Eligibility criteria included participants with RH or RA, followed from their first therapeutic thoracentesis/second paracentesis until death or transplantation. The primary outcome was LRD with non-LRD or transplantation as competing risk. Of 2552 patients with cirrhosis who underwent therapeutic thoracentesis/paracentesis, 177 met criteria for RH and 422 for RA. RH was associated with a significantly higher risk of LRD (adjusted hazard ratio [aHR] = 4.63, 95% confidence interval [CI]: 3.31–6.48) than RA overall and within all MELD-sodium (MELD-Na) strata (< 10 aHR = 4.08, 95% CI: 2.30–7.24; 10–14.9 aHR = 5.68, 95% CI: 2.63–12.28; 15–24.9 aHR = 4.14, 95% CI: 2.34–7.34; ≥ 25 aHR = 7.75, 95% CI: 2.99–20.12). LRD was higher among participants requiring 1 (aHR = 3.54, 95% CI: 2.29–5.48), 2–3 (aHR = 4.39, 95% CI: 2.91–6.63), and ≥ 4 (aHR = 7.89, 95% CI: 4.82–12.93) thoracenteses relative to RA. Although participants with RH and RA had similar baseline MELD-Na, LRD occurred in RH versus RA at a lower MELD-Na (16.5 vs. 21.82, p = 0.002) but higher MELD 3.0 (27.85 vs. 22.48, p < 0.0001).
Conclusions: Refractory hepatic hydrothorax (RH) was associated with higher risk of liver-related death (LRD) than refractory ascites at equivalent MELD-sodium. By contrast, MELD 3.0 may better predict risk of LRD in RH.