Beneficial haemodynamic and renal sodium handling effects of combined midodrine and octreotide treatment in a cirrhotic patient with large hepatic hydrothorax and mild ascites

Sir,

Hepatic hydrothorax complicates advanced liver cirrhosis resulting from the transfer of ascitic fluid into the pleural space in the absence of primary cardiopulmonary disease and, occasionally, of clinically evident ascites. When management with sodium restriction and diuretics fails and repeated thoracenteses are needed, potentially dangerous invasive procedures, such as pleurodesis, thoracoscopic repair of diaphragmatic defects with pleural sclerosis or transjugular intrahepatic portosystemic shunting should be considered [1]. Recently, octreotide-induced natriuresis and reduction of hepatic hydrothorax was described [2,3]. We report on a case of hepatic hydrothorax, which resolved after adding the {alpha}-adrenergic agonist midodrine to octreotide.

A large sterile right hepatic hydrothorax was diagnosed in a 66-year-old female with hepatitis C virus (HCV) cirrhosis (Child class C) with mild ascites and deteriorating dyspnoea. Increasing doses of spironolactone and furosemide induced marked hyponatraemia and encephalopathy without a reduction of the pleural effusion, and repeated paracenteses were required. Diuretics were discontinued and octreotide 600 mg/day was commenced on day 1; mean arterial pressure (MAP) was 80 mmHg, cardiac output (CO) 7.32 l/min, serum urea (Ure) 7.6 mmol/l, serum creatinine (Cre) 88.4 µmol/l, serum sodium (Na) 124 mmol/l, urinary sodium (UNa) 16 mmol/day, urinary volume (UV) 1100 ml/day, glomerular filtration rate (GFR) with Tc99m-DTPA 112 ml/min, effective renal plasma flow (ERPF) with Tc99m-MAG3 615 ml/min, plasma active renin (PAR) 119 µU/ml, plasma aldosterone (PA) 82.5 ng/dl, plasma antidiuretic hormone (ADH) 8.5 pg/ml and plasma glucagon 298 pg/ml. On day 8, PAR, PA and plasma glucagon were 45.8 µU/ml, 39.4 ng/dl and 184 pg/ml, respectively, but ADH remained high (7.4 pg/ml). Octreotide did not improve the MAP (76 mmHg), CO (7.39 l/min) or renal function (Ure 7.3 mmol/l, Cre 97.2 µmol/l, Na 127 mmol/l, UNa 11 mmol/day, UV 850 ml/day, GFR 91 ml/min) despite an increase in ERPF (876 ml/min). The pleural effusion was not mobilized by octreotide whereas it decreased gradually after adding oral midodrine, up to 10 mg t.i.d., to octreotide. On day 17, the MAP was 98 mmHg, CO 6.02 l/min, Ure 5.2 mmol/l, Cre 79.5 µmol/l, Na 133 mmol/l, UNa 165 mmol/day, UV 2900 ml/day, GFR 138 ml/min, ERPF 866 ml/min, PAR 17.3 µU/ml, PA 17.6 ng/dl, ADH 3.5 pg/ml and plasma glucagon 192 pg/ml. Thereafter, she received octreotide 600 mg thrice weekly, midodrine 7.5 t.i.d., furosemide 40 mg/day and spironolactone 100 mg/day without recurrence of the hepatic hydrothorax until her death 4 months later.

Splanchnic arterial vasodilation with reflex activation of sodium- and water-retaining systems is involved in the pathogenesis of cirrhotic ascites and related pleural effusion [1]. Chronic octreotide administration seems to disrupt the circulatory homeostasis in decompensated cirrhotics by directly inhibiting the renin–angiotensin–aldosterone axis. As a result, it improves ERPF but not systemic haemodynamics, GFR and natriuresis [4]. However, octreotide ameliorates the splanchnic arterial hyporeactivity to vasoconstrictors by suppressing glucagon secretion [5]. Indeed, recent observations suggest that octreotide could potentiate the beneficial haemodynamic and renal effects of midodrine in decompensated cirrhotics [4]. The combination of midodrine and octreotide could therefore be considered in the treatment of hepatic hydrothorax.

Conflict of interest statement. None declared.

Georgios Kalambokis1, Andreas Fotopoulos2, Michael Economou3 and Epameinondas V. Tsianos1,3

1 Department of Internal Medicine2 Department of Nuclear Medicine3 Department of Gastroenterology Medical School of Ioannina Ioanninar Greece Email: geodora{at}mail.gr

References

  1. Lazaridis KN, Frank JW, Krowka MJ, Kamath PS. Hepatic hydrothorax: pathogenesis, diagnosis and management. Am J Med 1999; 107: 262–267[CrossRef][ISI][Medline]
  2. Dumortier J, Leprêtre J, Scalone O et al. Successful treatment of hepatic hydrothorax with octreotide. Eur J Gastroenterol Hepatol 2000; 12: 817–820[ISI][Medline]
  3. Pfammater R, Quatropani C, Reichen J, Goke B, Wagner AC. Treatment of hepatic hydrothorax and reduction of chest tube output with octreotide. Eur J Gastroenterol Hepatol 2001; 13: 977–980[CrossRef][ISI][Medline]
  4. Kalambokis G, Economou M, Fotopoulos A et al. The effects of chronic treatment with octreotide versus octreotide plus midodrine on systemic hemodynamics and renal hemodynamics and function in nonazotemic cirrhotic patients with ascites. Am J Gastroenterol 2005; 100: 879–885[CrossRef][ISI][Medline]
  5. Wiest R, Tsai MH, Groszmann RJ. Octreotide potentiates PKC-dependent vasoconstrictors in portal hypertensive and control rats. Gastroenterology 2001; 120: 975–983[CrossRef][ISI][Medline]




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