Noradrenaline for reverting hepatorenal syndrome: a prospective, observational, single-center study

Abstract

ObjectiveTo evaluate the effectiveness of noradrenaline for the treatment of hepatorenal syndrome (HRS).BackgroundHRS represents the development of renal failure in cirrhotic patients. The standard treatment for HRS is terlipressin, which, as opposed to noradrenaline, is more expensive and less accessible in most tertiary care centers.Patients and methodsThirty consecutive patients with HRS type 1 received noradrenaline (1–4.0 mg/hour) and albumin for 14 days. The parameters recorded were: serum creatinine levels, creatinine clearance, mean arterial pressure (MAP), urine output, and serum sodium levels evaluated at baseline and on treatment days 1, 3, 7, and 14.ResultsMost patients achieved serum creatinine levels <1.5 mg/dL and were considered responders (22/30, 73%), whereas eight patients (27%) were nonresponders. At baseline, responders and nonresponders differed only regarding initial bilirubin levels and international normalized ratio values. Treatment duration was 7.5±3.2 days. Responders experienced a significant (p<0.05) decrease in serum creatinine levels (from 3.26±0.48 to 1.28±0.14 mg/dL), as well as a significant increase (p<0.05) in creatinine clearance (from 21±4.1 to 67.7±12.1 mL/min), urine output (from 583±41.1 to 1163±105 mL/day), MAP (from 79.2±2.94 to 93.9±2.34 mmHg), and serum sodium levels (from 125±2.01 to 132.3±1.39 mEq/L). In nonresponders, the MAP increased, but serum creatinine levels also increased, reflecting a decrease in creatinine clearance and urine output, with no significant change in serum sodium levels over the duration of the treatment.ConclusionIn most patients, noradrenaline treatment induced systemic vasoconstriction resulting in HRS reversal, with acceptable safety, in agreement with previously reported outcomes of terlipressin treatment.

News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document

“…In patients with HRS-1, noradrenaline was shown to be as effective as terlipressin in the treatment of HRS in two small controlled clinical trials 70,71 and in a recent prospective study. 82 However, in a recent randomised trial, terlipressin was shown to be more effective than noradrenaline in the treatment of HRS in patients with ACLF; 83 this is probably related to the fact that noradrenaline, unlike terlipressin, has no effect on portal pressure 84 or on the expression of inducible NOS. 85 Despite these limitations, the use of norepinephrine for the treatment of HRS is tempting because it is a cheaper than terlipressin, although it should be administered through a central venous line and under continuous monitoring, so it cannot be used outside intensive care units.…”

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan

“…124 Noradrenaline at a dose of 0.5-3mg/h is infused continuously dose is gradually increased to achieve a raise in arterial blood pressure and improvement in renal parameters in HRS-AKI. 125,126 In a metaanalysis that extracted data from four studies only, no difference in reversal of HRS, 30-day mortality or recurrence of HRS was seen between terlipressin and norepinephrine. [127][128][129][130] Whereas terlipressin has been associated with cardiovascular and ischemic complications, norepinephrine was shown to have lower incidence of such adverse events.…”

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

“…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 . It would be interesting to know the details of the vasopressors that were used in this study apart from terlipressin.…”

“…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 …”