S5551 Fatal Respiratory Failure Following Terlipressin Administration for Hepatorenal Syndrome: A Case Report

Introduction: Hepatorenal syndrome (HRS) is a life-threatening complication of advanced liver disease characterized by functional renal failure. Terlipressin is a vasopressin analog widely used as the first-line pharmacotherapy for HRS. While it improves renal function, concerns regarding its effects on the respiratory and cardiovascular systems remain. This report describes a case of fatal respiratory failure associated with terlipressin in a patient with HRS. Case Description/Methods: A 62-year-old woman with alcoholic cirrhosis presented with progressive fatigue and jaundice. She was diagnosed with acute liver failure with an international normalized ratio of 2.6, ammonia 77 umol/L, aspartate aminotransferase 173 IU/L, alanine aminotransferase 83 IU/L, and bilirubin 16.4 mg/dL. On hospital day (HD) 4, she developed oliguria with rising serum creatinine from 0.5 to 4.05 mg/dL despite fluid resuscitation. Diagnosis of type 1 HRS was made, and she was initiated on albumin and terlipressin without improvement in renal function over the next 2 days. On HD 6, she developed respiratory failure with severe pulmonary edema on chest X-ray and hypoxemia on blood gas. She was intubated and transferred to the intensive care unit. Despite mechanical ventilation, diuresis, and stopping terlipressin, her respiratory status continued to decline. She developed severe metabolic acidosis despite continuous renal replacement therapy and progressed to multiorgan failure. Following the family’s wishes, care was withdrawn, and she passed away on HD 7. Discussion: Although liver transplant remains the treatment of choice for HRS, it is limited by patients’ short life expectancy and organ shortage. Terlipressin is more widely used due to its efficacy, feasibility, and potential use as transplant bridging therapy. It raises systemic blood pressure and improves renal perfusion by decreasing portal pressure and reducing systemic vasodilatation. The CONFIRM trial showed that death due to respiratory conditions 90 days after the first dose occurred significantly more in patients who received terlipressin than placebo. Respiratory failure associated with terlipressin is hypothesized to be driven by hydrostatic pulmonary edema from increased cardiac preload and afterload, with a potential additive effect from capillary leak in patients with multiorgan dysfunction. Early recognition and discontinuation of terlipressin are crucial, but progression can be rapid and irreversible. This case underscores the importance of close respiratory monitoring and risk stratification in patients receiving terlipressin.