Thread by @ebtapper

A patient with #cirrhosis and hepatic hydrothorax was admitted to an ICU 3 times for severe shortness of breath and hypoxia for urgent thoracentesis and diuretics

So we put in an indwelling catheter

Within weeks the output was minimal

What happened?

🧵
#livertwitter

This patient had ascites (weekly paras), hydrothorax, & high MELD including INR of 1.9, and plt 32.

She was small, weak. Sarcopenic.

Her creatinine 1.3.

Did you know that creatinine over-estimates renal function in women with #cirrhosis?

See MELD-Grail: aasldpubs.onlinelibrary.wiley.com/doi/abs/10.100… @AsraniSumeet

Before her paracentesis, they gave her FFP and platelets

After her paracentesis, albumin

Then she started needing thoracentesis

She was getting sicker

FFP is often given to "correct the INR". Platelets transfused to raise the count over a 'threshold'.

Yet

many professional societies (AASLD, AGA, ACG, SIR, ISTH) say not to do this

because these dont help patients with cirrhosis avoid bleeding from paracentesis.

Worse

Those transfusions may hurt some patients:

Left: Raising their portal pressure
Right: Increasing risk of circulatory overload, more common in #cirrhosis (PMID: 29300236)

And what about Albumin?

like most things it has a therapeutic window

Left: Give it to people with SBP, 👍
Right: Give *some* people without SBP too much, pulmonary edema👎(PMID: 33657293)

Why would people with #cirrhosis get pulmonary edema?

1. Too much fluid can do it to anyone
2. Decreased renal function
3. High prevalence of diastolic and systolic heart dysfunction - cc: @manhalizzy

So what happened to my patient?

When we put in the catheter, she didnt need thoras.
When she didnt need thoras, she didnt get FFP, Platelets.
When she didnt get FFP/Plts, she had less ascites production, less hydrothorax
Then we pulled the tube
Then she got a transplant

In summary:

❤️cardiac dysfunction is common in #cirrhosis
🫘 Renal function is overestimated by creatinine in #cirrhosis, particularly for women and those with sarcopenia
🩸'prophylactic transfusions' can have harms like volume overload, albumin too
#livertwitter

I have wanted to tell this #liverstory for a while. Because I think about it a lot. Felt inspired by @theliverdr who is THE professional liverstoryologist