Liver and Bile
Hepatology. 2024;79(5):1048–64
Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography
Background and aims: Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefits, but may be associated with cardiopulmonary complications. The authors analyzed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo) and cardiac and renal biomarkers. Approach: Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6 hours of admission, at the time of starting terlipressin (48 h), and at 72 hours. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic cardiomyopathy (CCM) was defined per 2020 criteria.
Results: 140 patients were enrolled (84% men, 59% alcohol-associated disease, mean MELD-Na 25 ± standard deviation [SD] 5.6). A median daily dose of infused terlipressin was 4.3 mg/day (interquartile range, 3.9–4.6); mean duration 6.4 ± SD 1.9 days; the complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cut-offs for prediction of terlipressin non-response were cardiac variables (ratio of early mitral inflow velocity and mitral annular early diastolic tissue doppler velocity > 12.5 [indicating increased left filling pressures, C-statistic: 0.774], tissue doppler mitral velocity < 7 cm/s [indicating impaired relaxation; C-statistic: 0.791], > 20.5% reduction in cardiac index at 72 hours [C-statistic: 0.885]; p < 0.001) and pretreatment biomarkers (cystatin C > 2.2 mg/l, C-statistic: 0.640 and N-terminal brain natriuretic peptide > 350 pg/ml, C-statistic: 0.655; p < 0.050). About 6% of all patients with HRS-AKI and 26% of patients with CCM had pulmonary edema. The presence of CCM (adjusted hazard ratio [aHR] = 1.9; 95% confidence interval [CI]: 1.8–4.5, p = 0.009) and terlipressin non-response (aHR = 5.2; 95% CI: 2.2–12.2, p < 0.001) were predictors of mortality independent of age, sex, obesity, diabetes mellitus, etiology, and baseline creatinine.
Conclusions: Cirrhotic cardiomyopathy (CCM) and reduction in cardiac index, reliably predict terlipressin non-response. CCM is independently associated with poor survival in hepatorenal syndrome-acute kidney injury.