Background: Hepatorenal syndrome (HRS) is functional renal failure occurring in advanced stage liver disease associated with poor prognosis. The best treatment is liver transplantation. Terlipressin is effective in treatment of HRS but noradrenaline has been suggested as cheaper and readily available alternative and we aimed to compare the efficacy of noradrenaline and terlipressin in patients with HRS.Methods: 30 patients were allocated to each group and group A received infusion of noradrenaline at dose of 0.5 mg/hr (maximum 3 mg/hr) and group B received terlipressin at dose 1 mg intravenously 6 hourly until reversal of HRS or completion of 7 days of therapy. Intravenous albumin (20 g/day) was given to both groups. Decrease in serum creatinine and increase in daily urine output and mean arterial pressure (MAP) helped us in comparison.Results: Out of 60 cirrhotics screened, 51 were randomised into group A (N=22) or group B (N=29). Baseline characteristics of both groups were similar. In group A, 0% showed complete response while 31.8% showed partial response but majority (68.2%) showed no response. In group B, 89.7% showed complete response and 6.9% showed partial response. Decrease in serum creatinine in both groups (group A- 3.91±1.58 mg/dl to 3.07±1.68 mg/dl; group B- 3.21±1.24 mg/dl to 1.36±0.87 mg/dl). Both groups showed an increase in MAP (group A- 76.93±6.18 mmHg to 89.49±6.93 mmHg; group B- 75.54±5.51 mmHg to 89.92±5.07 mmHg).Conclusions: Noradrenaline was not as effective as terlipressin in treatment of HRS.

Severe hypercalcemia is a life-threatening condition. Hypercalcemia of malignancy can occur as a result of 4 different mechanisms, the most common mechanism being humoral hypercalcemia of malignancy (HHM). The second most common mechanism that majorly concerns our case is osteolytic hypercalcemia. In patients with osseous metastases, increased cytokine activity in the region of lytic osseous metastatic lesions greatly stimulate the activity of osteoclasts in the bone. When compensatory mechanisms are exceeded, the serum calcium level rises causing hypercalcemia. Symptoms and signs include nausea and vomiting, fatigue, depression, confusion, psychosis, abdominal pain, constipation, acute pancreatitis, peptic ulceration, polyuria/nocturia, hematuria, renal colic, renal failure, bone pain, hypertension, and arrhythmias. We present this case of severe hypercalcemia to emphasize the severity of disease associated with lytic skeletal metastasis with an emphasis on early management, diagnosis, and interventions to prevent early mortality.