Terlipressin in brain-death donors

Duodenal Necrosis and Nonvariceal Digestive Bleeding After Terlipressin Administration for Treatment of Hepatorenal Syndrome: a Case Report of a Novel Side Effect of a Commonly Used Drug

BACKGROUND

Terlipressin is widely used for treatment of hepatorenal syndrome and variceal bleeding in cirrhotic patients. However, it may be associated with side effects, especially those related to vasoconstriction, such as myocardial infarction or intestinal ischemia. This is a case report of a cirrhotic patient with nonvariceal upper gastrointestinal bleeding after duodenal necrosis due to the use of terlipressin, a novel side effect not yet described in literature to the best of our knowledge.

CASE REPORT

A 51-year-old male patient, with alcoholic liver cirrhosis and hepatitis C virus infection, was admitted presenting oliguria associated with severe ascites and lower limb edema. His Model for End Stage Liver Disease-Sodium score was 19 and his serum creatine level was 2.12 mg/dL. Albumin infusion was performed for 48 hours, but his serum creatinine level reached 3.46 mg/dL. Terlipressin infusion was started in continuous infusion and serum creatinine levels progressively decreased. However, the patient presented hemorrhagic shock secondary to hematemesis after 7 days. Upper digestive endoscopy showed an extensive ulcerated lesion in the duodenal bulb, reaching 70% of its lumen, with hematic residues and necrotic foci. Terlipressin was suspended and proton pump inhibitors were started. Despite intensive care, the patient developed severe encephalopathy and reentrant seizures. He eventually died 10 days after the bleeding event.

CONCLUSIONS

We described a case of nonvariceal upper gastrointestinal bleeding secondary to duodenal necrosis, which was caused by visceral ischemia induced by terlipressin. Given its fatality potential, this novel side effect should be remembered when using this medication in cirrhotic patients.

Effects of Terlipressin on Management of Hypotensive Brain-Dead Patients Who are Potential Organ Donors: A Retrospective Study

Background: Administration of terlipressin can reverse hypotension in potential organ donors with norepinephrine-resistance. The aim of this study was to determine the effects of terlipressin on the hemodynamics, liver function, and renal function of hypotensive brain-dead patients who were potential organ donors.

Methods: A retrospective study was conducted by using the ICU database of one hospital. 18 patients in a total of 294 brain-dead cases were enrolled and administered terlipressin intravenously. All physiological parameters of recruited patients were obtained at baseline, 24 and 72 h after administration, and immediately before organ procurement.

Results: Terlipressin induced significant increases in mean arterial pressure (MAP) from 69.56 ± 10.68 mm Hg (baseline) to 101.82 ± 19.27 mm Hg (immediately before organ procurement) and systolic blood pressure (SBP) from 89.78 ± 8.53 mm Hg (baseline) to 133.42 ± 26.11 mm Hg (immediately before organ procurement) in all patients. The increases in MAP were accompanied by significant decreases in heart rate (HR) from 113.56 ± 28.43 bpm (baseline) to 83.89 ± 11.70 bpm (immediately before organ procurement), which resulted in the decrease of norepinephrine dose over time from 0.8 ± 0.2 μg/kg/min (baseline) to 0.09 ± 0.02 μg/kg/min (immediately before organ procurement). There were no changes in central venous pressure, liver function including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin. Renal function, assessed by serum creatinine (SCr), urine output (UOP), creatinine clearance rate (CCr), and estimated glomerular filtration rate (eGFR), improved significantly.

Conclusion: Our analysis of brain-dead patients with hypotension indicates that administration of terlipressin can significantly increases MAP, SBP, UOP, CCr, and eGFR, while decreases HR and Scr. Terlipressin appears to help maintain hemodynamic stability, reduce vasoactive support, and improve renal function.

Vasopressin vs Terlipressin in Treatment of Refractory Shock

Arginine vasopressin (AVP) and its synthetic, long-acting analog terlipressin (TP) are potent alternative vasoconstrictors in the treatment of septic patients with catecholamine-refractive vasodilatatory shock. Recent clinical data suggest that early administration of AVP analogues may be advantageous compared to a last resort therapy. However, it is still unknown whether vasopressin and terlipressin are equally effective for hemodynamic support in shock. Despite important pharmacological differences between the two drugs the use of either substance is determined mainly by local availability and institutional inventory. The current literature suggests that neither AVP nor TP should be administered in high doses in shock. Furthermore, increasing evidence indicates that early administration of terlipressin may improve outcome as compared to a last-resort treatment. Low-dose infusion of AVP has been demonstrated to be a safe adjunct in the management of refractory shock. Evidence from experimental studies and initial clinical reports suggests that continuous low-dose infusion of TP may stabilize hemodynamics in shock. In this review we briefly described differences in pharmacokinetics and pharmacodynamics between AVP and Terlipressin (TP) in treatment of refractory shock.

Dopamine Use in Intensive Care: Are We Ready to Turn it Down?

Dopamine is still frequently used as a first line vasopressor agent in hypotensive patients, when physicians are afraid of noradrenaline and believe that dopamine, with its β and α, inotrope and vasopressor effects, may be helpful. Evidence exists that it does not offer protection from renal failure, even if at low doses (0, 3-5 mcg/Kg/min) it may exert its effects on D1 and D2 receptors resulting in natriuresis and renal vasodilation, augmentation in renal blood flow, and diuresis. The effects of dopamine on gastrointestinal system and splanchnic perfusion in critical care patients are even more controversial, since they seem to be at least partially dependent on the initial fractional splanchnic blood flow. Dopamine may exert deleterious effects on respiratory function, by impairing the ventilatory drive response to hypoxemia and hypercapnia and reducing arterial oxygen saturation through a regional ventilation/perfusion mismatching. Dopamine seems to affect the cellular mediated mechanism of the immune function directly by its action on receptors located on immune system cells and indirectly altering the hormonal response regulating immune response. In this paper, the use of low dose dopamine is discussed in the intensive care perspective.

Minimally invasive Swine experimental model for the in vivo study of liver metabolism of drugs

PURPOSE

To develop a clinically relevant porcine model for the study of hepatic metabolism of drugs by means of hepatic vein catheterization.

MATERIALS AND METHODS

review of literature and elaboration of a hypothesis, design of an experimental method.

RESULTS

recent clinical studies were conducted by withdrawing cirrhotic patients' blood from right hepatic vein during hepatic vein pressure gradient measurements. Basing on our personal clinical experience and evaluation of research needs, an experimental model is proposed.

CONCLUSIONS

contemporary measurement of peripheral and hepatic concentration of drugs by peripheral vein and hepatic vein catheterization can be used to create a reliable and reproducible porcine model to study liver metabolism of drugs in vivo.