Hepatorenal syndrome

COST EFFECTIVENESS OF USING TERLIPRESSIN TO TREAT HEPATORENAL SYNDROME

BACKGROUND

Hepatorenal syndrome (HRS) is the most severe form of acute kidney injury in patients with advanced cirrhosis, and it is associated with high mortality. It is usually diagnosed according to criteria defined by the International Ascites Club. Currently, the most frequently indicated pharmacological therapy for the treatment of HRS is a combination of splanchnic vasoconstrictors (terlipressin or norepinephrine) in combination with albumin. With the progressive increase in healthcare spending, it is important to conduct a cost-effectiveness analysis of pharmacological treatment in patients who are diagnosed with HRS.

OBJECTIVE

To perform a cost-effectiveness assessment for the use of terlipressin in combination with albumin to treat HRS in patients with cirrhosis.

METHODS

Economic evaluation of cost-effectiveness based on secondary data from studies showed the efficacy of terlipressin therapy compared with norepinephrine combined with albumin or albumin alone. The cost-effectiveness analysis was calculated using an incremental cost-effectiveness ratio (ICER), and a sensitivity analysis was developed by varying the values of therapies and probabilities. The Brazilian real was the currency used in the analysis, and the results were converted to US dollars.

RESULTS

After selection, eligibility, and evaluation of the quality of publications, the results demonstrated that administration of terlipressin or norepinephrine in combination with albumin in patients diagnosed with HRS type 1 was efficacious. The cost of treatment with terlipressin in combination with albumin was USD $1,644.06, administration of albumin alone was USD $912.02, and norepinephrine plus albumin was USD $2,310.78. Considering that the combination therapies demonstrated effectiveness, the incremental cost of terlipressin and norepinephrine in combination with albumin was USD $666.73, and an effectiveness of 0.570 was found for terlipressin in combination with albumin and 0.200 for norepinephrine in combination with albumin. The incremental effectiveness was 0.370, and the ICER was USD $1,801.97. Thus, the parameters of increasing cost per therapy and ICER indicated that the combined therapy of terlipressin plus albumin was cost effective compared to albumin alone or norepinephrine plus albumin in a public single-payer healthcare system.

CONCLUSION

A cost-effectiveness analysis showed that terlipressin in combination with albumin when administered concomitantly to patients who were diagnosed with type 1 HRS is cost-effective compared to norepinephrine in combination with albumin administered in a controlled environment.

Acute renal dysfunction in patients with alcoholic hepatitis

Acute renal dysfunction is common in patients with alcoholic hepatitis (AH). Its presence leads to higher mortality in these patients. Despite advances in medical care, the outcome has changed little over the past decades. Studies using Pentoxifylline and molecular adsorbent recirculation system have shown encouraging data in small studies. Further larger well designed studies are needed to assess these modalities of treatment for the treatment of AH.

Management of Cirrhosis and Associated Complications

Liver cirrhosis is the encapsulation or replacement of injured tissue by collagen, resulting in end-stage liver disease and portal hypertension. The consequences of cirrhosis are impaired hepatocyte function, increase intrahepatic circulatory resistance, portal hypertension, and the development of hepatocellular carcinoma. Complications include encephalopathy, coagulopathy, varices, ascites, spontaneous bacterial peritonitis, epatorenal syndrome, and hepatopulmonary syndrome. Managing patients with acute or chronic liver failure is challenging, and liver failure may have profound effects on other organ systems. Most therapies are directed at managing the complications and bridging patients to liver transplantation. The clinician must be aware of the pathologic presentations and the appropriate management, including pharmacologic and nonpharmacologic therapies, goals and end points of therapy, and monitoring of therapy. This review focuses on the management of the complications directly associated with liver dysfunction (encephalopathy and coagulopathy) and portal hypertension (varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome).

Treatment of hepatorenal syndrome

<zakljucak> Hepatorenalni sindrom je funkcionalna insuficijencija bubrega u sklopu terminalne insuficijencije jetre. U patogenezi ovog sindroma ucestvuju hemodinamske promene (snizeni srednji arterijski pritisak i perfuzioni pritisak bubrega) i povecano stvaranje sistemskih i bubreznih vazoaktivnih medijatora sa stimulacijom bubreznog simpatickog sistema. Standardna medicinska farmakoloska terapija usmerena je na prethodno navedene patofizioloske poremecaje. U poslednje vreme postupci detoksikacije, npr. jedan od vidova albuminske dijalize, pojavljuju se sve vise u lecenju bolesnika sa HRS, ali se jos ne preporucuju kao standardna procedura. Oba vida lecenja preduzimaju se samo kao premoscenje perioda do transplantacije jetre ili u slucajevima kada se ocekuje oporavak funkcije jetre, jer bubrezna funkcija direktno zavisi od funkcije jetre. Standardna hemodijaliza ne pomaze u poboljsanju funkcije bubrega. Jedino kauzalno resenje ovog problema donosi transplantacija jetre.