Real‐world treatment patterns and outcomes using terlipressin in 203 patients with the hepatorenal syndrome

Abstract

Summary Background Hepatorenal syndrome and acute kidney injury are common complications of decompensated cirrhosis, and terlipressin is recommended as first‐line vasoconstrictor therapy. However, data on its use outside of clinical trials are lacking. Aims To assess practice patterns and outcomes around vasoconstrictor use for hepatorenal syndrome in UK hospitals. Methods This was a multicentre chart review study. Data were extracted from medical records of patients diagnosed with hepatorenal syndrome and treated by vasoconstrictor drugs between January 2013 and December 2017 at 26 hospitals in the United Kingdom. The primary outcome was improvement of kidney function, defined as complete response (serum creatinine improved to ≤1.5 mg/dL), partial response (serum creatinine reduction of ≥20% but >1.5 mg/dL) and overall response (complete or partial response). Other outcomes included need for dialysis, mortality, liver transplantation and adverse events. Results Of the 225 patients included in the analysis, 203 (90%) were treated with terlipressin (median duration, 6 days; range: 2‐24 days). Mean (±standard deviation) serum creatinine at vasopressor initiation was 3.25 ± 1.64 mg/dL. Terlipressin overall response rate was 73%. Overall response was higher in patients with mild acute kidney injury (baseline serum creatinine <2.25 mg/dL), compared to those with moderate (serum creatinine ≥2.25 mg/dL and <3.5 mg/dL) or severe (serum creatinine ≥3.5 mg/dL). Ninety‐day survival was 86% for all patients (93% for overall responders vs 66% for treatment nonresponders, P < 0.0001). Conclusion Terlipressin is the most commonly prescribed vasoconstrictor for patients with hepatorenal syndrome in the United Kingdom. Treatment with terlipressin in patients with less severe acute kidney injury (serum creatinine <2.25 mg/dL) was associated with higher treatment responses, and 90‐day survival.

Letter: HRS‐AKI – a frequent misdiagnosis in the real‐world setting?

“…However, diagnosing ascites by clinical examination is straightforward and its absence makes one question the diagnosis of HRS‐AKI. The major precipitants of HRS in this study were infections and gastrointestinal bleeding 1 . Some of these patients may have had hypotension which may have led to the preferential use of vasopressors over terlipressin with consequent lower response rate in patients receiving other vasopressors.…”

“…HRS cannot be diagnosed in the presence of hypotension and we would like to know the number of patients with hypotension in the study cohort. Apart from these factors, only a small number of patients received other vasopressors, which may have led to the discrepant observations in this group 1,3‐6 …”

“…It is intriguing that almost 25% of patients did not have ascites. Significantly fewer patients receiving other vasopressors (41%) had ascites than those who received terlipressin (79%) 1 . Ascites is a prerequisite for diagnosing HRS.…”

“…The authors observed that treatment with terlipressin was associated with better overall and complete response than treatment with other vasopressors 1 . While midodrine and octreotide combination has been associated with inferior response in comparison to terlipressin, several randomised trials have demonstrated similar responses with noradrenaline and terlipressin 3‐6 .…”

“…We read the study by Moore et al with great interest 1 . The study reported the practice patterns and outcomes of vasoconstrictor use in patients with hepatorenal syndrome (HRS) in the United Kingdom.…”