The Role of Terlipressin in AKI Secondary to Hepatorenal Syndrome (AKI-HRS)

Introduction: Terlipressin is the most common vasoconstrictor used worldwide. It can be administered as a first-line agent for treatment of Acute Kidney injury secondary to Hepatorenal Syndrome. The pathophysiology includes increased intrahepatic resistance and vascular tone. Activation of the vasodilatory response leads to both splanchnic and systemic vasodilation. Progressive vasodilation leads to vasoconstrictive system activation, resulting in decreased blood flow to kidneys and the development of Acute kidney injury. Case Description: We represent a case of a 74-year-old male with a past medical history of decompensated cirrhosis secondary to alcohol use disorder and HCV infection, HTN, OSA, Atrial flutter, and COPD presented to the Emergency Department with a three-day history of abdominal pain, distension and shortness of breath. On presentation vitals were B.P 108/61, HR>110. Physical examination showed a distended abdomen with ascites. Labs included serum creatinine>2.8 (baseline serum creat>0.9) and cystatin C 2.68. Abdominal sonogram normal. The patient was admitted to MICU for Decompensated Cirrhosis complicated with Hepatorenal syndrome and hepatic encephalopathy. The patient was given albumin challenge 25gm q6H, midodrine and octreotide for 2 days, and Terlipressin for 3 days. Lactulose and rifaximin was also started. Renal function markedly improved from serum creat 2.8 to serum creat 1.2. after the terlipressin was initiated. The patient got clinically better and was downgraded to floors. Discussion: In one of the large randomized controlled trials, the efficacy of terlipressin was proven with some additional side effects of pulmonary edema. Therefore, caution should be taken before using terlipressin in patients with volume overload like anasarca, jugular venous distention, hypoxemia secondary to pulmonary congestion, and elevated right ventricular systolic pressures. Other possible options for treatment of AKI-HRS include placement of Trans jugular intrahepatic portosystemic shunt to decrease portal hypertension and Liver transplantation with kidney transplantation if there was prolonged damage to the kidneys. AKI-HRS prevention includes preventing volume depletion through careful use of diuretics, and lactulose, prevention of variceal bleeding, and discontinuation of nephrotoxic medications such as Ace/Arbs, Nsaids, contrast, and certain antibiotics.