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Bielawski AM, Frishman WH. A Review of Terlipressin in Hepatorenal Syndrome: Targeting Endothelial Dysfunction and Subsequent Cardiovascular Adverse Events. Cardiol Rev 2024:00045415-990000000-00249. [PMID: 38832784 DOI: 10.1097/crd.0000000000000697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Hepatorenal syndrome (HRS) is a serious complication of decompensated liver cirrhosis that results in acute kidney injury (AKI). The mortality rate is high. Endothelial dysfunction secondary to liver cirrhosis is a key driver of the development of portal hypertension, which is eventually complicated by ascites and HRS. Ultimately, splanchnic vasodilation and excess gut lymph production result in ascites, low effective arterial blood volume, and maladaptive compensatory mechanisms that contribute to renal hypoperfusion and injury. While the only curative treatment is liver transplantation, vasoconstrictors and albumin have been the mainstay of treatment for candidates who are ineligible or waiting for transplantation. On September 14, 2022, terlipressin, a V1 vasopressin receptor agonist, was approved by the Food and Drug Administration for the treatment of HRS-AKI. In clinical trials, terlipressin plus albumin have been superior to albumin alone and equivocal to noradrenaline plus albumin in renal function improvement. Terlipressin, however, does not improve survival, is costly, and is associated with severe adverse events-including severe cardiac and vascular complications. The aim of this review is to provide an overview of terlipressin pharmacology, adverse events-with a focus on cardiovascular complications-and comparative randomized controlled trials that resulted in the Food and Drug Administration's approval of terlipressin. New literature since its approval and ongoing clinical trials will also be highlighted.
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Affiliation(s)
- Adrienne M Bielawski
- From the Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
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Kulkarni AV, Lee J, Reddy KR. Terlipressin in the management of adults with hepatorenal syndrome-acute kidney injury (HRS-AKI). Expert Rev Gastroenterol Hepatol 2023; 17:1067-1079. [PMID: 37856367 DOI: 10.1080/17474124.2023.2273494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/17/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Kidney is the most common extra-hepatic organ involved in patients with advanced liver cirrhosis and acute-on-chronic liver failure. Hepatorenal syndrome-acute kidney injury (HRS-AKI) accounts for most hospitalizations, and liver transplantation (LT) remains the ultimate and long-term treatment in such patients. However, HRS-AKI, being a functional renal failure, has a fair chance of reversal, and as such, patients who achieve reversal of HRS-AKI have better outcomes post-LT. AREAS COVERED In this review, we discuss the pharmacokinetics, pharmacodynamics and evidence to support the use of terlipressin in HRS-AKI while we also address predictors of response and the associated adverse events. Further, we discuss the role of terlipressin in the context of LT. EXPERT OPINION The recommended treatment for HRS-AKI reversal includes a vasoconstrictor in addition to volume expansion with albumin. The three vasoconstrictor regimens generally used to treat HRS-AKI include octreotide plus midodrine, noradrenaline, and terlipressin. Of these, terlipressin is a widely used drug and has been recently approved by US Food and Drug Administration (USFDA) for HRS-AKI. Terlipressin is the most effective drug for HRS-AKI reversal and is associated with a decreased need for renal replacement therapy pre- and post-transplant. Furthermore, terlipressin responders have improved transplant-free and post-transplant survival.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jason Lee
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA
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Abstract
Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects profoundly disturbed procoagulant-anticoagulant balance in susceptible tissue beds secondary to circulatory shock (cardiogenic, septic). There is a characteristic SPG triad: (a) shock (hypotension, lactic acidemia, normoblastemia, multiple organ dysfunction), (b) disseminated intravascular coagulation (DIC), and (c) natural anticoagulant depletion (protein C, antithrombin). In recent years, risk factors for natural anticoagulant depletion have been identified, most notably acute ischemic hepatitis ("shock liver"), which is seen in at least 90% of patients who develop SPG. Moreover, there is a characteristic time interval (2-5 days, median 3 days) between the onset of shock/shock liver and the beginning of ischemic injury secondary to peripheral microthrombosis ("limb ischemia with pulses"), reflecting the time required to develop severe depletion in hepatically-synthesized natural anticoagulants. Other risk factors for natural anticoagulant depletion include chronic liver disease (e.g., cirrhosis) and, possibly, transfusion of colloids (albumin, high-dose immunoglobulin) lacking coagulation factors. A causal role for vasopressor therapy is unproven and is unlikely; this is because critically ill patients who develop SPG do so usually after at least 36-48 hours of vasopressor therapy, implicating a time-dependent pathophysiological mechanism. The most plausible explanation is a progressive time-dependent decline in key natural anticoagulant factors, reflecting ongoing DIC ("consumption"), proximate liver disease whether acute or chronic ("impaired production"), and colloid administration ("hemodilution"). Given these evolving concepts of pathogenesis, a rationale approach to prevention/treatment of SPG can be developed.
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Affiliation(s)
- Theodore E Warkentin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; Service of Clinical Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Shuoyan Ning
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
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Kulkarni AV, Kumar P, Rao NP, Reddy N. Terlipressin-induced ischaemic skin necrosis. BMJ Case Rep 2020; 13:13/1/e233089. [PMID: 31948983 DOI: 10.1136/bcr-2019-233089] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Terlipressin is a commonly used drug in hepatology practice for the two most serious complications of cirrhosis, that is, acute oesophageal variceal bleed and hepatorenal syndrome. Acute-on-chronic liver failure (ACLF) is a medical emergency and is frequently associated with acute kidney injury (AKI). Two male patients with alcohol-induced ACLF with high MELD (Model for End-Stage Liver Disease) score presented with AKI. Both were treated with terlipressin infusion. There was no response to terlipressin in these sick patients, and further both patients developed ischaemic skin necrosis and succumbed to multiorgan failure. Continuous infusion of terlipressin is superior to bolus dosing, but we noted that continuous infusion might as well be associated with severe adverse effects in patients with a high MELD score. More extensive prospective studies, including patients with high MELD score, are required to ascertain the safety of terlipressin.
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Affiliation(s)
- Anand V Kulkarni
- Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Pramod Kumar
- Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nagaraj P Rao
- Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar Reddy
- Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Chiang CW, Lin YJ, Huang YB. Terlipressin-Induced Peripheral Cyanosis in a Patient with Liver Cirrhosis and Hepatorenal Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:5-9. [PMID: 30600312 PMCID: PMC6325660 DOI: 10.12659/ajcr.913150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatorenal syndrome (HRS), which is a type of functional renal impairment, is one of the most serious complications in patients with liver cirrhosis. Terlipressin can induce splanchnic vasoconstriction, which increases the renal blood flow and has beneficial effects on HRS. However, terlipressin administration may cause serious ischemic complications such as skin ischemia, peripheral gangrene, and ischemic bowel necrosis. Here, we report a case of peripheral cyanosis following terlipressin administration in a cirrhotic patient with HRS. CASE REPORT The patient was a 65-year-old male. He was considered to have type-1 HRS, and thus, terlipressin was administered. However, peripheral cyanosis involving the fingers, toes, area around an umbilical hernia, and scrotum was noted. Thus, terlipressin administration was discontinued. Subsequently, his condition rapidly improved. CONCLUSIONS We reported a case of peripheral cyanosis following terlipressin administration, which resolved after discontinuation of terlipressin administration. It is important to recognize the early signs of side effects and discontinue the administration of the suspected drug immediately.
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Affiliation(s)
- Chi-Wen Chiang
- Division of Pharmacy, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan.,School of Pharmacy, Master Program in Clinical Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yun-Ju Lin
- Division of Nursing, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan
| | - Yaw-Bin Huang
- School of Pharmacy, Master Program in Clinical Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Symmetrical Peripheral Gangrene: Mechanisms for Limb Loss in the ICU in Patients With Retained Pulses. ACTA ACUST UNITED AC 2018. [DOI: 10.1097/cpm.0000000000000253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ghatak T, Poddar B, Mahindra S. Left ventricular failure and left ventricular inferior wall hypokinesia following terlipressin injection. Ann Card Anaesth 2015; 17:257-9. [PMID: 24994746 DOI: 10.4103/0971-9784.135897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tanmoy Ghatak
- Department of Critical Care Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
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Carmo LS, Baima DC, Blefari V, Zonta V, Troncon LE, Rossi MA. Involvement of the microvasculature in the pathogenesis of terlipressin-related myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 5:505-511. [PMID: 24855284 DOI: 10.1177/2048872614534921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 04/18/2014] [Indexed: 11/16/2022]
Abstract
We report an autopsy case of a 24-year-old man with diagnoses of advanced alcoholic liver cirrhosis, portal hypertension, and esophageal variceal bleeding that presented extensive myocardial infarction after treatment with terlipressin. On postmortem examination the cut surface of the heart presented myocardial infarction implicating the left ventricle free wall, apex of the heart and ventricular septum. Light microscopic examination revealed that the extensive area of cardiac infarction was the result of the sum of diffuse foci of microinfarction of various ages interspersed with small clusters of preserved myocytes. Moreover, the epicardial vessels were patent while the small intramyocardial vessels presented thickened wall, apparent reduction in lumen diameter and disruption of endothelial cells indicative of spasm. The observations in this case allow clear insight into the involvement of the microcirculation in the pathogenesis of myocardial infarction with the use of terlipressin.
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Affiliation(s)
- Lucas S Carmo
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Diego C Baima
- Department of Medicine, Division of Gastroenterology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Valdecir Blefari
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Vaniela Zonta
- Department of Medicine, Division of Gastroenterology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Luiz Ea Troncon
- Department of Medicine, Division of Gastroenterology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Marcos A Rossi
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Brazil.,Marcos A Rossi passed away on 9 May 2013
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Mansor NA, Zain ZM, Hamzah HH, Noorden MSA, Jaapar SS, Beni V, Ibupoto ZH. Detection of Breast Cancer 1 (BRCA1) Gene Using an Electrochemical DNA Biosensor Based on Immobilized ZnO Nanowires. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojab.2014.32002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Longrois D, Guinot PG, Depoix JP. [Regulation of vasomotor tone]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31 Suppl 1:S25-S30. [PMID: 22721518 DOI: 10.1016/s0750-7658(12)70051-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This article provides a synthesis of physiology and pathophysiology of the cardiovascular system and briefly presents the principles of regulation at the level of the whole organism and regional circulations. Decision algorithms, based on knowledge of physiology and pathophysiology are proposed. Their goal is to contribute to the improvement of cardiopulmonary bypass practice.
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Affiliation(s)
- D Longrois
- Diderot, Sorbonne Paris Cité, Unité INSERM U698, Université Paris 7, 46, rue Henri Huchard, 75877 Paris cedex 18, France.
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