Terlipressin for the treatment of hepatorenal syndrome: an overview of current evidence

Mean arterial pressure drop is an independent risk factor of hepatorenal syndrome in patients with HBV-ACLF

BACKGROUND/AIMS

In patients with acute-on-chronic liver failure (ACLF), type 1 hepatorenal syndrome (HRS) is a critical organ failure complication that resulted in rapid mortality. There are no efficient parameters to predict HRS in hepatitis B virus (HBV)-related ACLF. To assess HBV-ACLF risk factors and evaluate the association between mean arterial pressures (MAP), HRS and survival in patients with HBV-ACLF.

METHODS

A total of 420 ACLF patients were screened from June 2015 to June 2016, and 57 HBV-ACLF patients were included in the study. Clinical data and MAP measurements of these patients were collected. Multivariate analyses, Cox proportional hazards regression and receiver operator characteristic (ROC) curves were used to analyze.

RESULTS

In a 30-day study period, 43 (75.44%) patients survived. Patients in the HRS group were older and had higher Model for End-Stage Liver Disease (MELD) scores than patients in the non-HRS group. A MAP drop of ≥9.5 mmHg was an independent predictor of HRS with a sensitivity and specificity of 92.86 and 69.77%, respectively. The baseline MELD score was also an independent risk factor of HRS. MAP drop (OR, 1.582; P = 0.000), prothrombin time, HRS, MELD and FIB were independent prognostic factors for 30-day mortality. The area under the ROC curve of MAP drop was 0.808 (P = 0.001).

CONCLUSION

A decrease in MAP was a valuable predictor of HRS in patients with HBV-related ACLF. MAP drop ≥9.5 mmHg may be useful for predicting patient prognosis and exploring new treatment measures in patients with HBV-related ACLF.

Midodrine and albumin versus albumin alone for the secondary prophylaxis of acute kidney injury in a patient with cirrhosis and ascites

BACKGROUND

Acute kidney injury (AKI) in a patient with cirrhosis has high short-term mortality. Midodrine has shown promising results in the treatment of AKI-hepatorenal syndrome (HRS-AKI).

AIMS

To compare midodrine and albumin versus albumin alone for the secondary prophylaxis of HRS-AKI.

PATIENTS AND METHOD

Open labeled, nonrandomized, pilot study. Patients with a diagnosis of HRS-AKI were recruited after complete recovery. Patients were given midodrine daily (15 mg) and injection albumin infusion 20 g weekly in group-A (Gp-A) and injection albumin 20 g weekly with no midodrine in group-B (Gp-B). The primary endpoint was the recurrence of AKI-HRS, and the secondary endpoint was ascites tap in 2-month period.

RESULTS

A total of 42 patients were enrolled in Gp-A, n = 22, and Gp-B, n = 20. There was no significant difference between the groups (Gp-A vs. Gp-B) in terms of age, model stage liver disease, Child-Turcotte-Pugh score and serum creatinine at inclusion (1.27 ± 0.1 vs. 1.22 ± 0.2 mg/dL). During follow up ten patients (50%) in Gp-B and four patients (18%) in Gp-A develop HRS-AKI (P = 0.04). The mean number of ascites tap was significantly higher in Gp-B compared to Gp-A (2.6 ± 0.5 vs. 1.9 ± 0.5) in 2 months. There was a significant increase in mean arterial pressure in Gp-A compared to Gp-B on days 7, 15, 30, 45 and 60. There was a significant difference in mean arterial pressure at day 7 in patients who developed HRS-AKI versus those who did not develop HRS-AKI [(n = 14, 65.5 ± 5.5) vs. (n = 28,74.6 ± 9.2 mm Hg), P = 0.02].

CONCLUSIONS

Midodrine along with albumin infusion, is helpful in the secondary prophylaxis of HRS-AKI and reduces the number of ascites tap. However, a large randomized study is required for further validation.

Norepinephrine is More Effective Than Midodrine/Octreotide in Patients With Hepatorenal Syndrome-Acute Kidney Injury: A Randomized Controlled Trial

Background: Terlipressin is the first-line pharmacological treatment for hepatorenal syndrome. When terlipressin is unavailable, midodrine/octreotide or norepinephrine, with albumin, represent the alternative treatments. The comparative efficacy of these alternative regimens remains unclear.

Objective: To compare the efficacy of midodrine/octreotide to that of norepinephrine for the treatment of patients with hepatorenal syndrome.

Methods: In the intensive care setting, sixty patients with hepatorenal syndrome were randomized to initially receive either 0.5 mg/h of norepinephrine (maximum 3 mg/h) or 5 mg of oral midodrine three times/day (maximum 12.5 mg three times/day) plus octreotide (100 μg/6 h) as subcutaneous injection (maximum 200 μg/6 h), together with albumin (20–40 g/day). Treatment was allowed for a maximum of 10 days. Survival was analyzed for up to 30 days. The primary efficacy outcome was the proportion of patients who achieved full response, defined as the return of serum creatinine to a value within 0.3 mg/dl of the baseline at the end of treatment.

Results: There was a significantly higher rate of full response in the norepinephrine group (15/26, 57.60%) than the midodrine/octreotide group (5/25, 20%) (p = 0.006). Eleven (42.30%) patients in the norepinephrine group and 6 (24%) in the midodrine/octreotide group survived (p = 0.166).

Conclusion: Norepinephrine plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with hepatorenal syndrome.

(ClinicalTrials.gov, identifier: NCT03455322).

https://clinicaltrials.gov/ct2/show/NCT03455322?cond = Hepatorenal+Syndrome&cntry = EG&draw = 2&rank = 1.

An investigation of reconstituted terlipressin infusion stability for use in hepatorenal syndrome

Hepatorenal syndrome (HRS) is a fatal complication of renal dysfunction associated with ascites, liver failure and advanced cirrhosis. Although the best option for long-term survival is liver transplantation, in the critical acute phase, vasoconstrictors are considered first-line supportive agents. Terlipressin is the most widely used vasoconstrictor globally but owing to its short elimination half-life, it is usually administered six hourly by slow intravenous bolus injection. This requires patients to remain in hospital, increasing hospital bed costs and affecting their quality of life. An alternative option for administration of terlipressin is as a continuous infusion using an elastomeric infusor device in the patient’s home. However, stability data on terlipressin in elastomeric infusor devices is lacking. This research aimed to evaluate the stability of terlipressin reconstituted in infusor devices for up to 7 days at 2–8 °C and subsequently at 22.5 °C for 24 h, to mimic home storage and administration temperatures. We report that terlipressin was physically and chemically stable under these conditions; all reconstituted infusor concentrations retained above 90% of the original concentration over the test conditions. No colour change or precipitation in the solutions were evident.

Pharmacological management of portal hypertension and its complications in children: lessons from adults and opportunities for the future

INTRODUCTION

Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children.

AREAS COVERED

The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored.

EXPERT OPINION

Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.

Terlipressin May Decrease In-Hospital Mortality of Cirrhotic Patients with Acute Gastrointestinal Bleeding and Renal Dysfunction: A Retrospective Multicenter Observational Study

BACKGROUND

Acute gastrointestinal bleeding (GIB) rapidly reduces effective blood volume, thereby precipitating acute kidney injury (AKI). Terlipressin, which can induce splanchnic vasoconstriction and increase renal perfusion, has been recommended for acute GIB and hepatorenal syndrome in liver cirrhosis. Thus, we hypothesized that terlipressin might be beneficial for cirrhotic patients with acute GIB and renal impairment.

METHODS

In this Chinese multi-center study, 1644 cirrhotic patients with acute GIB were retrospectively enrolled. AKI was defined according to the International Club of Ascites (ICA) criteria. Renal dysfunction was defined as serum creatinine (sCr) > 133 μmol/L at admission and/or any time point during hospitalization. Incidence of renal impairment and in-hospital mortality were the primary end-points.

RESULTS

The incidence of any stage ICA-AKI, ICA-AKI stages 1B, 2, and 3, and renal dysfunction in cirrhotic patients with acute GIB was 7.1%, 1.8%, and 5.0%, respectively. The in-hospital mortality was significantly increased by renal dysfunction (14.5% vs. 2.2%, P < 0.001) and ICA-AKI stages 1B, 2, and 3 (11.1% vs. 2.8%, P = 0.011), but not any stage ICA-AKI (5.7% vs. 2.7%, P = 0.083). The in-hospital mortality was significantly decreased by terlipressin in patients with renal dysfunction (3.6% vs. 20.0%, P = 0.044), but not in those with any stage ICA-AKI (4.5% vs. 6.0%, P = 0.799) or ICA-AKI stages 1B, 2, and 3 (0.0% vs. 14.3%, P = 0.326).

CONCLUSION

Renal dysfunction increased the in-hospital mortality of cirrhotic patients with acute GIB. Terlipressin might decrease the in-hospital mortality of cirrhotic patients with acute GIB and renal dysfunction.

TRIAL REGISTRATION

NCT03846180 ( https://clinicaltrials.gov ).

Development of hyponatremia after terlipressin in cirrhotic patients with acute gastrointestinal bleeding: a retrospective multicenter observational study

Background: Terlipressin can effectively control acute gastrointestinal bleeding (GIB) in cirrhotic patients by acting on the V1 receptors, but may lead to the development of dilutional hyponatremia by acting on the V2 receptors.Research design and methods: This retrospective multicenter study enrolled 674 cirrhotic patients with acute GIB in whom serum sodium concentrations were tested before and during the use of terlipressin. ΔSodium reduction ≥5 mmol/L, hyponatremia (sodium <130 mmol/L), and severe hyponatremia (sodium <125 mmol/L) during the use of terlipressin were evaluated. Logistic regression analyses were employed to identify the risk factors.Results: The incidence of Δsodium reduction ≥5 mmol/L, hyponatremia, and severe hyponatremia was 37.1%, 26.3%, and 13.0%, respectively. All of them were not significantly associated with in-hospital mortality (p = 0.973; p = 0.789; p = 0.887). In multivariate logistic regression analyses, the independent risk factors of Δsodium reduction ≥5 mmol/L were higher baseline sodium concentration, lower serum creatinine and prothrombin time, and larger dosage of terlipressin; those of hyponatremia were lower baseline sodium concentration and longer duration of terlipressin; those of severe hyponatremia were lower baseline sodium concentration and prothrombin time and longer duration of terlipressin.Conclusions: Hyponatremia was common in cirrhotic patients with acute GIB treated with terlipressin, but might not significantly increase the in-hospital mortality.

Effect of terlipressin on renal function in cirrhotic patients with acute upper gastrointestinal bleeding

BACKGROUND

Renal dysfunction is a serious morbidity in cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB). Terlipressin is the first-line treatment choice for acute variceal bleeding and hepatorenal syndrome (HRS). This study aimed to assess the effect of terlipressin on renal function in patients with liver cirrhosis and AUGIB.

METHODS

We retrospectively reviewed 40 cirrhotic patients with AUGIB treated with terlipressin by an attending physician between January 2016 and June 2018. We analyzed the change of renal function parameters, including cystatin C (CysC) and creatinine (Cr), during the use of terlipressin and after terlipressin was stopped. We also identified the factors associated with renal function improvement in patients without active bleeding during the use of terlipressin.

RESULTS

During the use of terlipressin, CysC value was significantly reduced (1.3±0.8 vs. 1.1±0.7, P=0.001); Cr value was reduced, but the reduction was not statistically significant (68.8±24 vs. 65.5±23, P=0.817); the rate of CysC reduction was significantly higher in patients treated with terlipressin than those treated with somatostatin/octreotide (73.1% vs. 0%, P=0.005); the rate of Cr reduction was not significantly different between patients treated with terlipressin and somatostatin/octreotide (61.5% vs. 20%, P=0.148); no factor associated with CysC reduction was identified; higher hemoglobin, red blood cell, and platelet and lower prothrombin time and international normalized ratio at baseline were significantly associated with Cr reduction. After terlipressin was stopped, neither CysC nor Cr value was significantly reduced (P=0.852 and P=0.296).

CONCLUSIONS

Terlipressin may be beneficial on preventing renal function impairment in cirrhotic patients with AUGIB.