Symptomatic pleural effusion in adult liver transplant candidates: prevalence, disease severity and post-transplant mortality

Symptomatic pleural effusion in patients with decompensated cirrhosis—often termed hepatic hydrothorax—is thought to reflect advanced disease and may carry poor prognosis. However, its impact on outcomes after liver transplantation remains uncertain. In this retrospective cohort study, we evaluated all adult patients who underwent their first liver transplantation at a single tertiary centre between 2015 and 2022. Baseline demographics, clinical characteristics and disease severity scores were extracted from institutional databases. The presence of symptomatic pleural effusion requiring therapeutic intervention was determined from imaging reports and clinical records. Multivariable logistic regression was used to assess associations between pleural effusion and mortality at 30 days, 90 days and overall, adjusting for age, sex, Model for End-Stage Liver Disease (MELD) score and ascites. Of 459 transplant candidates, 59 (12.8%) had symptomatic pleural effusion. These patients displayed higher MELD scores and a greater prevalence of ascites compared with those without effusion, though age and sex distributions were similar. Unadjusted mortality rates were higher in the effusion group (20.3%, 28.8% and 33.9% at 30 days, 90 days and overall, respectively), but in multivariable analyses pleural effusion was not an independent predictor of mortality at any time point. MELD score showed a borderline association with early mortality. Symptomatic pleural effusion is common among liver transplant candidates and is associated with more advanced liver disease, yet it does not independently increase post-transplant mortality. These findings suggest that pleural effusion should prompt careful optimisation of ascites and early transplant evaluation but need not preclude transplantation. Future studies should explore effusion characteristics and management strategies to better stratify risk.