Prophylactic Perioperative Terlipressin Therapy for Preventing Acute Kidney Injury in Living Donor Liver Transplant Recipients: A Systematic Review and Meta-Analysis

Abstract

Background: Acute kidney injury (AKI) is common in the perioperative transplant period and is associated with poor outcomes. Few studies reported a reduction in AKI incidence with terlipressin therapy by counteracting the hemodynamic alterations occurring during liver transplantation. However, the effect of terlipressin on posttransplant outcomes has not been systematically reviewed. Methods: A comprehensive search of electronic databases was performed. Studies reporting the use of terlipressin in the perioperative period of living donor liver transplantation were included. We expressed the dichotomous outcomes as risk ratio (RR, 95% confidence interval [CI]) using the random effects model. The primary aim was to assess the posttransplant risk of AKI. The secondary aims were to assess the need for renal replacement therapy (RRT), vasopressors, effect on hemodynamics, blood loss during surgery, hospital and intensive care unit (ICU) stay, and in-hospital mortality. Results: A total of nine studies reporting 711 patients (309 patients in the terlipressin group and 402 in the control group) were included for analysis. Terlipressin was administered for a mean duration of 53.44 ± 28.61 h postsurgery. The risk of AKI was lower with terlipressin (0.6 [95% CI, 0.44-0.8]; P = 0.001). However, on sensitivity analysis including only four randomized controlled trials (I 2 = 0; P = 0.54), the risk of AKI was similar in both the groups (0.7 [0.43-1.09]; P = 0.11). The need for RRT was similar in both the groups (0.75 [0.35-1.56]; P = 0.44). Terlipressin therapy reduced the need for another vasopressor (0.34 [0.25-0.47]; P < 0.001) with a concomitant rise in mean arterial pressure and systemic vascular resistance by 3.2 mm Hg (1.64-4.7; P < 0.001) and 77.64 dyne cm À1 .sec À5 (21.27-134; P = 0.007), respectively. Blood loss, duration of hospital/ICU stay, and mortality were similar in both groups. Conclusions: Perioperative terlipressin therapy has no clinically relevant benefit. ( J CLIN EXP HEPATOL xxxx;xxx:xxx)

Intraoperative Vasoactive Medications and Perioperative Outcomes in Liver Transplantation: A Systematic Review and Network Meta-analyses

“…A total of 4271 citations were retrieved and screened after duplicate removal, including 4 meta-analyses used for supplemental screening (Supplemental Material Section 1 and Figure S1, SDC, http://links.lww.com/TP/C835). [45][46][47][48] We included 25 RCTs (Figure S1, SDC, http://links.lww. com/TP/C835; Table 1).…”

“…A total of 4271 citations were retrieved and screened after duplicate removal, including 4 meta-analyses used for supplemental screening ( Supplemental Material Section 1 and Figure S1, SDC , http://links.lww.com/TP/C835). 45-48 We included 25 RCTs ( Figure S1, SDC , http://links.lww.com/TP/C835; Table 1). 49-73 Detailed interventions and main cointerventions used in individual studies (fluid management and coagulation management protocols) are reported in Table 1.…”

“…Based on very low QoE, no effect of somatostatin was observed regarding biliary stenosis or acute rejection, and none of the studies observed an event of graft dysfunction in either group (Table 4; Table S20 and Figure S11, SDC, http://links.lww.com/TP/C835). Two studies comparing different vasodilator infusions reported the incidence of graft dysfunction 64,66 and 1 reported the Fenoldopam 45 [42][43][44][45][46][47][48][49][50] 11 (24) -72 ( 18) 46 (100) 0 (0) --535 (155) 0 (0) Low-dose dopamine 50 [46][47][48][49][50][51][52][53][54]…”

Acute-on-chronic liver failure: Terminology, mechanisms and management

“…(1,38) During the treatment, the resolution of AKI has a good prognosis (38-40%), and the progression of AKI has a mortality rate of approximately 75%. (38)(39)(40)(41) Biomarkers like NGAL, KIM-1, and IL-18 can be of some help in predicting renal failure and the development of ATN. (38)(39)(40)(41)(42)…”

“…(38)(39)(40)(41) Biomarkers like NGAL, KIM-1, and IL-18 can be of some help in predicting renal failure and the development of ATN. (38)(39)(40)(41)(42)…”