Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Clinical research and biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Clinical research and biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
BACKGROUND Hepatorenal syndrome (HRS) carries a high short-term mortality in patients with cirrhosis and ACLF. Terlipressin and noradrenaline are routinely used in cirrhosis with HRS and have been found to be equally effective. There is no data comparing the efficacy of terlipressin with noradrenaline in ACLF patients with HRS. METHODS In an open-label RCT, consecutive patients with ACLF diagnosed with
HRS-AKI, were randomised to albumin with infusion of terlipressin (2-12 mg/d) (n=60) or noradrenaline (0.5-3 mg/hr) (n=60). The response to treatment, course of AKI and outcome were studied. RESULTS Baseline characteristics including AKI stage and sepsis-related HRS-AKI were comparable between the groups. Compared to noradrenaline, terlipressin achieved greater day4 (26.1% vs.11.7%,p=0.03) and day 7 (41.7% vs. 20%,p=0.01) response. Reversal of HRS was also better with terlipressin (40% vs.16.7%,p=0.004) with a significant reduction in the requirement of renal replacement therapy(56.6% vs. 80%,p=0.006)and improved 28-day survival (48.3% vs. 20%,p=0.001). Adverse events limiting use of drugs were higher with terlipressin than noradrenaline[23.3% versus 8.3%,p=0.02], but were reversible. On multivariate analysis, high MELD (OR 1.10, CI=1.009-1.20,p=0.03) and noradrenaline compared to terlipressin (OR 3.05,CI=1.27-7.33,p=0.01)predicted non-response to therapy. Use ofnoradrenaline compared to terlipressin was also predictive of higher mortality (HR 2.08, CI=1.323.30,p=0.002). CONCLUSIONS Acute kidney injury in ACLF carries a high mortality. Infusion of terlipressin gives earlier and higher response than noradrenaline with improved survival in ACLF patients with HRS-AKI. This article is protected by copyright. All rights reserved.
