Terlipressin for Hepatorenal Syndrome: Continuous Infusion as an Alternative to IV Bolus Administration

Vasoconstrictor therapy with terlipressin and concomitant albumin can improve renal function in patients with hepatorenal syndrome (HRS). The recent publication of the first 2 randomized controlled trials has received great attention. Sanyal et al,2 with a bolus dose regimen of 4 mg/d, which could be increased to 8 mg/d, achieved reversal of HRS type 1 in 34% of 56 patients. Serious adverse events, mostly cardiovascular, considered to be treatment related were observed in 9% of patients. By comparison, the Spanish trial using a bolus regimen of 6 mg starting dose, which could be doubled to 12 mg/d, observed renal response to the combination of terlipressin and albumin in 6 of 17 patients with type 1 HRS, corresponding to 35%. Cardiovascular complications occurred in 43% of patients in the terlipressin arm, and even after excluding circulatory overload, there was still a 22% complication rate, including myocardial infarction. Accordingly, the editorial3 raised several important questions and concerns such as uncertainty about the optimal dose and timing of terlipressin and the potential for severe ischemic events. It was recommended that terlipressin should be used only in an intensive care unit or a unit with hemodynamic monitoring because of the severe adverse events.