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Reddy KR, Weinberg EM, Gonzalez SA, Izzy MJ, Simonetto DA, Frederick RT, Rubin RA, Fricker Z, Ikahihifo-Bender J, Harte M, Garcia S, Campbell K, Olofson A, Razavi RF, James JM, Patel H, Kim-Lee G, Witkiewicz S, Tobin W, Jamil K. Safety and efficacy of continuous terlipressin infusion in HRS-AKI in a transplant population. Liver Transpl 2024:01445473-990000000-00385. [PMID: 38771635 DOI: 10.1097/lvt.0000000000000399] [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] [Received: 12/02/2023] [Accepted: 05/06/2024] [Indexed: 05/23/2024]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI) is associated with significant morbidity and mortality. While liver transplantation is the definitive treatment, continuous terlipressin infusion for HRS-AKI may provide benefit and, as such, was assessed in a population composed of candidates for liver transplant (LT). Fifty hospitalized LT-eligible patients with HRS-AKI received a single bolus followed by continuous terlipressin infusion. Acute-on-chronic liver failure grade 3, serum creatinine (SCr)>5.0 mg/dL, or Model for End-Stage Liver Disease (MELD) ≥35 were exclusions. Fifty hospitalized patients who received midodrine and octreotide or norepinephrine for HRS-AKI served as a historical comparator cohort. Complete response (CR) was defined as a ≥30% decrease in SCr with end-of-treatment (EOT) SCr≤1.5, partial response as a ≥30% decrease in SCr with EOT SCr>1.5, and nonresponse as a <30% decrease in SCr. CR rate was significantly higher in the terlipressin cohort compared to the historical cohort (64% vs. 16%, p <0.001). Survival, while numerically higher in those who received terlipressin, was statistically similar (D30: 94% vs. 82%, p =0.12; D90: 78% vs. 68%, p =0.37). Renal replacement therapy (RRT) was more common among terlipressin NR than CR and PR (70% vs. 3% vs. 13%, p < 0.001). EOT MELD and SCr were significantly lower within terlipressin cohort (MELD: 19 vs. 25, SCr: 1.4 vs. 2.1 mg/dL, p <0.001). Sixteen of 40 terlipressin-treated patients received LT-alone (terlipressin CR in 10/16). One patient on terlipressin had a hypoxic respiratory failure that responded to diuretics; one possibly had drug-related rash. With continuous terlipressin infusion, a CR rate of 64% was observed with a favorable safety profile. Terlipressin use was associated with lower EOT MELD and SCr than the historical midodrine and octreotide/norepinephrine cohort; LT-alone was accomplished in a high proportion of complete terlipressin responders.
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Affiliation(s)
- K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stevan A Gonzalez
- Division of Hepatology, Department of Medicine, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas, USA
| | - Manhal J Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - R Todd Frederick
- Division of Hepatology, Department of Advanced Organ Therapies and Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Raymond A Rubin
- Department of Transplantation, Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jade Ikahihifo-Bender
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Maggie Harte
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sandra Garcia
- Division of Hepatology, Department of Medicine, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas, USA
| | - Kathryn Campbell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy Olofson
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Ryan F Razavi
- Division of Hepatology, Department of Advanced Organ Therapies and Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Janelle M James
- Department of Transplantation, Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Het Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Kim-Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - William Tobin
- International HealthCare, LLC, Norwalk, Connecticut, USA
| | - Khurram Jamil
- Formerly at Department of Research & Development, Mallinckrodt Pharmaceuticals, Scientific Affairs, Bridgewater, New Jersey, USA
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Sharma B, Bhateja A, Sharma R, Chauhan A, Bodh V. Acute kidney injury in acute liver failure: A narrative review. Indian J Gastroenterol 2024; 43:377-386. [PMID: 38578564 DOI: 10.1007/s12664-024-01559-5] [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: 12/30/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024]
Abstract
Acute kidney injury (AKI) is a frequent complication of acute liver failure (ALF) and it worsens the already worse prognoses of ALF. ALF is an uncommon disease, with varying etiologies and varying definitions in different parts of the world. There is limited literature on the impact of AKI on the outcome of ALF with or without transplantation. The multifaceted etiology of AKI in ALF encompasses factors such as hemodynamic instability, systemic inflammation, sepsis and direct nephrotoxicity. Indications of renal replacement therapy (RRT) for AKI in ALF patients extend beyond the conventional criteria for dialysis and continuous renal replacement therapy (CRRT) may have a role in transplant-free survival or bridge to liver transplantation (LT). LT is a life-saving option for ALF, so despite somewhat lower survival rates of LT in ALF patients with AKI, LT is not usually deferred. In this review, we will discuss the guidelines' recommended definition and classification of AKI in ALF, the impact of AKI in ALF, the pathophysiology of AKI and the role of CRRT and LT in ALF patients with AKI.
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Affiliation(s)
- Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Anshul Bhateja
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Rajesh Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Ashish Chauhan
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Vishal Bodh
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India.
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Katiyar H, Tiwari P, Bhadauria DS, Rai P, Goel A. Rescue use of Pegylated Interferon in Dialysis Patient who Failed to Respond Sofosbuvir. Indian J Nephrol 2023; 33:152-154. [PMID: 37234437 PMCID: PMC10208530 DOI: 10.4103/ijn.ijn_259_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/24/2021] [Accepted: 11/23/2021] [Indexed: 05/28/2023] Open
Affiliation(s)
- Harshita Katiyar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prachi Tiwari
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Dharmendra S. Bhadauria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Goel
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Belcher JM, Parada XV, Simonetto DA, Juncos LA, Karakala N, Wadei HM, Sharma P, Regner KR, Nadim MK, Garcia-Tsao G, Velez JCQ, Parikh SM, Chung RT, Allegretti AS. Terlipressin and the Treatment of Hepatorenal Syndrome: How the CONFIRM Trial Moves the Story Forward. Am J Kidney Dis 2021; 79:737-745. [PMID: 34606933 DOI: 10.1053/j.ajkd.2021.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/13/2021] [Indexed: 12/13/2022]
Abstract
Hepatorenal syndrome (HRS) is a form of acute kidney injury occurring in patients with advanced cirrhosis and is associated with significant morbidity and mortality. The pathophysiology underlying HRS begins with increasing portal pressures leading to the release of vasodilatory substances which result in pooling blood in the splanchnic system and a corresponding reduction in effective circulating volume. Compensatory activation of the sympathetic nervous system, renin-angiotensin-aldosterone system and release of arginine vasopressin serve to defend mean arterial pressure but at the cost of severe constriction of the renal vasculature, leading to a progressive, often fulminant form of AKI. While there are no approved treatments for HRS in the United States, multiple countries, including much of Europe, utilize terlipressin, a synthetic vasopressin analogue, as first-line therapy. The recently published CONFIRM trial, the third randomized trial based in North America evaluating terlipressin, met its primary endpoint, showing greater rates of HRS reversal in the terlipressin arm. However, due to concerns about apparent increased rates of respiratory adverse events and a lack of evidence for mortality benefit, terlipressin was not approved by the Food and Drug Administration (FDA). In this Perspective, we explore the history of regulatory approval for terlipressin in the United States, examine the results from CONFIRM and the concerns they raised and consider the future role of terlipressin in this critical clinical area of continued unmet need.
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Affiliation(s)
- Justin M Belcher
- Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA and Section of Nephrology, VA-Connecticut Healthcare System, West Haven, CT, USA.
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Luis A Juncos
- Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Nithin Karakala
- Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Hani M Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
| | | | - Samir M Parikh
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess and Harvard Medical School, Boston, MA, USA; Division of Nephrology, UT Southwestern, Dallas, TX
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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