Terlipressin and albumin for type-1 hepatorenal syndrome associated with sepsis

Background & Aims: Terlipressin and albumin is the standard of care for classical type-1 hepatorenal syndrome (HRS) not associated with active infections. However, there is no information on efficacy and safety of this treatment in patients with type-1 HRS associated with sepsis. Study aim was to investigate the effects of early treatment with terlipressin and albumin on circulatory and kidney function in patients with type-1 HRS and sepsis and assess factors predictive of response to therapy. Methods: Prospective study in 18 consecutive patients with type-1 HRS associated with sepsis. Results: Treatment was associated with marked improvement in arterial pressure and suppression of the high levels of plasma renin activity and norepinephrine. Response to therapy (serum creatinine < 1.5 mg/dl) was achieved in 12/18 patients (67%) and was associated with improved 3-month survival compared to patients without response. Non-responders had significantly lower baseline heart rate, poor liver function tests, slightly higher serum creatinine, and higher Child-Pugh and MELD scores compared to responders. Interestingly, non-responders had higher values of CLIF-SOFA score compared to responders (14 +/- 3 vs. 8 +/- 1, respectively p < 0.001), indicating greater severity of acute-on-chronic liver failure (ACLF). A CLIF-SOFA score >= 11 had 92% sensitivity and 100% specificity in predicting no response to therapy. No significant differences were observed between responders and non-responders in baseline urinary kidney bio-markers. Treatment was safe and no patient required withdrawal of terlipressin. Conclusions: Early treatment with terlipressin and albumin in patients with type-1 HRS associated with sepsis is effective and safe. Patients with associated severe ACLF are unlikely to respond to treatment. (c) 2014 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.