Terlipressin therapy for renal failure in cirrhosis

Renal failure is common in cirrhosis frequently due to hepatorenal syndrome (HRS). Terlipressin and albumin improve renal function with a trend to prolong survival in HRS, but prognostic factors with therapy have been poorly studied.

Forty-five cirrhotics seen consecutively in a single centre with renal failure defined as oliguria/anuria and/or rising creatinine and no response to volume loading, without intrinsic renal disease, sepsis, gastrointestinal bleeding [median Child-Pugh score 12(8-14)/Model for End-Stage Liver Disease 29(10-40)], had intravenous terlipressin and albumin and were audited retrospectively classified into three groups: group 1 HRS type 1 (15), group 2 HRS type 2 (11) and group 3(19): not fulfilling HRS 1 or 2 criteria. Baseline median creatinine was 1.7 (0.9-5.46) mg/dl and 30 (67%) had creatinine greater than 1.5 mg/dl. All 45 patients had initial colloid/albumin and 31 continued terlipressin (2-4 mg/day) for a median 8 (2-76) days.

Improvement in serum creatinine occurred in 23 (51%) [(1.3 mg/dl (0.6-3.9)] compared with baseline [1.7 mg/dl (0.92-3.75)] (P<0.001). In the multivariate analysis a greater reduction in creatinine between baseline and day 4 (95% confidence interval, odds ratio: 0.25) was associated with improved survival at 6 weeks.

Albumin and terlipressin improve renal failure in the absence of sepsis in cirrhosis independently of whether HRS criteria are fulfilled or not. Improvement at 4 days of therapy is associated with better survival. Randomized studies are needed for oliguria and rising creatinine in cirrhotics even if HRS criteria are not fulfilled.