Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: A randomized trial

Abstract

Hepatorenal syndrome (HRS), a serious complication of cirrhosis, is associated with high mortality without treatment. Terlipressin with albumin is effective in the reversal of HRS. Where terlipressin is not available, as in the United States, midodrine and octreotide with albumin are used as an alternative treatment of HRS. The aim was to compare the effectiveness of terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of HRS in a randomized controlled trial. Twenty‐seven patients were randomized to receive terlipressin with albumin (TERLI group) and 22 to receive midodrine and octreotide plus albumin (MID/OCT group). The TERLI group received terlipressin by intravenous infusion, initially 3 mg/24 hours, progressively increased to 12 mg/24 hours if there was no response. The MID/OCT group received midodrine orally at an initial dose of 7.5 mg thrice daily, with the dose increased to a maximum of 12.5 mg thrice daily, together with octreotide subcutaneously: initial dose 100 μg thrice daily and up to 200 μg thrice daily. Both groups received albumin intravenously 1 g/kg of body weight on day 1 and 20‐40 g/day thereafter. There was a significantly higher rate of recovery of renal function in the TERLI group (19/27, 70.4%) compared to the MID/OCT group (6/21, 28.6%), P = 0.01. Improvement in renal function and lower baseline Model for End‐Stage Liver Disease score were associated with better survival. Conclusion: Terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS (Hepatology 2015;62:567–574

An Update on Hepatorenal Syndrome

“…Furthermore, a recent study indicated that the efficacy of a midodrine plus octreotide regimen might not be as significant as previous studies suggested (17). In 2015, a randomised controlled trial of 49 patients comparing terlipressin with octreotide/midodrine illustrated a significantly higher rate of improvement in renal function with terlipressin (≥50% serum creatinine decrease, 70.4% vs. 28.6%, P = 0.01), although there was no significant difference in survival between the two groups (18). Terlipressin is a bridging option, despite its high cost, to liver transplantation in patients who are transplant candidates as it may improve both renal function and short-term survival for patients awaiting a liver transplant.…”

Keeping high model for end‐stage liver disease score liver transplantation candidates alive

“…40 However, terlipressin was superior to midodrine and octreotide in a randomized controlled trial. 41 In patients who require IV vasopressor support, use of norepinephrine is preferred in patients with cirrhosis because it has been shown to improve renal outcomes in patients with HRS. Notably, terlipressin was compared to norepinephrine for the treatment of HRS, and no difference was found between the interventions.…”

Reply

“…We appreciate the interest of Vasudevan et al in our article recently published in HEPATOLOGY (1) on the use of terlipressin by continuous infusion, a schedule we introduced in 2006 in the treatment of hepatorenal syndrome (HRS). (2) We read with interest their experience with the outpatient continuous infusion of terlipressin in patients with HRS on the liver transplant (LT) waiting list.…”