The Effect of Terlipressin on Renal Replacement Therapy in Patients with Hepatorenal Syndrome

Key Points

Hepatorenal syndrome type 1 (HRS-1) is an often fatal, but potentially reversible, kidney failure in patients with decompensated cirrhosis. Treatment with terlipressin in patients with HRS-1 is associated with a reduction in the need for RRT.

Background

Hepatorenal syndrome type 1 (HRS-1)—also known as hepatorenal syndrome-AKI (HRS-AKI)—is a rapidly progressing and usually fatal, but potentially reversible, kidney failure occurring in patients with decompensated cirrhosis. A large proportion of patients with HRS-1 require renal replacement therapy (RRT). Terlipressin demonstrated efficacy in reversing HRS and improving renal function in patients with HRS-1 in three phase III, randomized, clinical trials (RCTs; i.e. , OT-0401, REVERSE, and CONFIRM). However, these RCTs were not designed to evaluate the effect of terlipressin on the requirement of RRT. In this study, the effect of terlipressin on RRT requirements in the pooled phase III patient population was assessed.

Methods

For this retrospective analysis, data from patients who participated in the OT-0401, REVERSE, and CONFIRM studies were integrated in the largest-to-date randomized database (N =608).

Results

The need for RRT was significantly decreased in patients in the terlipressin group versus the placebo group by day 30 (28.1% versus 35.9%, respectively; P = 0.040) and day 60 (30.1% versus 37.9%, respectively; P = 0.045) in the pooled population and also postliver transplantation (LT) at day 60 (20.5% versus 40.3%, respectively; P = 0.008) and day 90 (25.3% versus 43.1%, respectively; P = 0.018). More patients were alive and RRT-free by day 90 in the overall population (36.9% versus 28.5%; P = 0.030) and among patients who received an LT (60.0% versus 39.7%; P = 0.010). Random assignment to receive terlipressin was an independent positive predictor of avoidance of RRT (P = 0.042); while higher baseline serum creatinine (sCr) level and Child-Pugh scores were negatively associated with RRT avoidance (P < 0.001 and P = 0.040, respectively).

Conclusions

Terlipressin decreased the requirement of RRT compared with placebo among patients with HRS-1, including those receiving LT. A lower sCr level at the beginning of therapy was associated with avoidance of RRT.

A Comparison of the Effects of Prolonged (>10 Hour) Low-flow Sevoflurane, High-flow Sevoflurane, and Low-flow Isoflurane Anaesthesia on Hepatorenal Function in Orthopaedic Patients

This study compared the effects of low-flow sevoflurane, high-flow sevoflurane and low-flow isoflurane on hepatorenal function during and after more than 10 hours of anaesthesia. Twenty-five patients scheduled for elective orthopaedic surgery were categorized into three groups; low-flow sevoflurane (fresh gas flow at 1 litre/min, n=9), high-flow sevoflurane (5 l/min, n=7), or low-flow isoflurane (1 l/min, n=9). Inspiratory compound A concentrations were measured. The groups had similar duration of anaesthesia and exposure to anaesthetic agents. The area under the curve of concentration (mean, SD) of compound A in the low-flow sevoflurane group (359.8, 106.1 ppm.h) was greater than that in the high-flow sevoflurane group (61.1, 29.3 ppm.h; P<0.01). All groups showed normal plasma creatinine and creatinine clearance, and transient postoperative increases in plasma alanine aminotrans-ferase and alpha glutathione-S-transferase, as well as urinary glucose and alpha glutathione-S-transferase, with no significant differences between groups. There were no significant relationships between the area under the curve of concentration of compound A and the biomarkers. These findings suggest that prolonged anaesthesia with low-flow sevoflurane has similar effects on hepatorenal function to prolonged anaesthesia with high-flow sevoflurane and low-flow isoflurane.

High expression of type I inositol 1,4,5-trisphosphate receptor in the kidney of rats with hepatorenal syndrome

AIM

To detect the expression of type I inositol 1,4,5-trisphosphate receptor (IP3RI) in the kidney of rats with hepatorenal syndrome (HRS).

METHODS

One hundred and twenty-five Sprague-Dawley rats were randomly divided into four groups to receive an intravenous injection of D-galactosamine (D-GalN) plus lipopolysaccharide (LPS; group G/L, n = 50), D-GalN alone (group G, n = 25), LPS alone (group L, n = 25), and normal saline (group NS, n = 25), respectively. At 3, 6, 9, 12, and 24 h after injection, blood, liver, and kidney samples were collected. Hematoxylin-eosin staining of liver tissue was performed to assess hepatocyte necrosis. Electron microscopy was used to observe ultrastructural changes in the kidney. Western blot analysis and real-time PCR were performed to detect the expression of IP3RI protein and mRNA in the kidney, respectively.

RESULTS

Hepatocyte necrosis was aggravated gradually, which was most significant at 12 h after treatment with D-galactosamine/lipopolysaccharide, and was characterized by massive hepatocyte necrosis. At the same time, serum levels of biochemical indicators including liver and kidney function indexes were all significantly changed. The structure of the renal glomerulus and tubules was normal at all time points. Western blot analysis indicated that IP3RI protein expression began to rise at 3 h (P < 0.05) and peaked at 12 h (P < 0.01). Real-time PCR demonstrated that IP3RI mRNA expression began to rise at 3 h (P < 0.05) and peaked at 9 h (P < 0.01).

CONCLUSION

IP3RI protein expression is increased in the kidney of HRS rats, and may be regulated at the transcriptional level.

Abnormal Expression of Urea Transporter Protein in a Rat Model of Hepatorenal Syndrome Induced by Succinylated Gelatin

BACKGROUND

Hepatorenal syndrome (HRS) is a serious complication of advanced chronic liver disease. Abdominal compartment syndrome (ACS) occurs with dysfunction of multiple organs when abdominal pressure increases. Here, we report on a novel model of ACS with ascites and a model of HRS in rats to observe the urea transporter protein (UT) expression in the 2 models.

MATERIAL AND METHODS

A liver cirrhosis model was induced by CCl4. After changes of liver histopathology were observed, rats were injected intraperitoneally with succinylated gelatin to establish a model of ACS and HRS. Then, changes in BUN, Cr, and renal histopathology were detected. Moreover, the UT in ACS and HRS were also quantified.

RESULTS

The surfaces of liver in the cirrhotic group became coarse, with visible small nodules and became yellow and greasy. The normal structure of the hepatic lobules were destroyed, and hyperplasia of fibrotic tissue and pseudo-lobe was observed. The levels of BUN and Cr were significantly increased in rats suffering from ACS and HRS, respectively, compared to their control groups. In addition, the mRNA levels of UT-A2 and UT-A3 decreased in rats with HRS compared to cirrhotic rats. However, there was no significant difference between the mRNA levels of UT-A2, UT-A3, and UT-B in rats with ACS vs. normal rats.

CONCLUSIONS

It is feasible to model ACS in rats by injecting succinylated gelatin into the abdominal cavity. Increasing the intra-abdominal pressure by succinylated gelatin is also a novel approach for modeling HRS in cirrhotic rats. Compared with control rats, there is an abnormal mRNA expression of UT in ACS rats and HRS rats.

Development of a rat model of D-galactosamine/lipopolysaccharide induced hepatorenal syndrome

AIM: To develop a practical and reproducible rat model of hepatorenal syndrome for further study of the pathophysiology of human hepatorenal syndrome.

METHODS: Sprague-Dawley rats were intravenously injected with D-galactosamine and lipopolysaccharide (LPS) via the tail vein to induce fulminant hepatic failure to develop a model of hepatorenal syndrome. Liver and kidney function tests and plasma cytokine levels were measured after D-galactosamine/LPS administration, and hepatic and renal pathology was studied. Glomerular filtration rate was detected in conscious rats using micro-osmotic pump technology with fluorescein isothiocyanate-labelled inulin as a surrogate marker.

RESULTS: Serum levels of biochemical indicators including liver and kidney function indexes and cytokines all significantly changed, especially at 12 h after D-galactosamine/LPS administration [alanine aminotransferase, 3389.5 ± 499.5 IU/L; blood urea nitrogen, 13.9 ± 1.3 mmol/L; Cr, 78.1 ± 2.9 μmol/L; K⁺, 6.1 ± 0.5 mmol/L; Na⁺, 130.9 ± 1.9 mmol/L; Cl^-, 90.2 ± 1.9 mmol/L; tumor necrosis factor-α, 1699.6 ± 599.1 pg/mL; endothelin-1, 95.9 ± 25.9 pg/mL; P < 0.05 compared with normal saline control group]. Hepatocyte necrosis was aggravated gradually, which was most significant at 12 h after treatment with D-galactosamine/LPS, and was characterized by massive hepatocyte necrosis, while the structures of glomeruli, proximal and distal tubules were normal. Glomerular filtration rate was significantly decreased to 30%-35% of the control group at 12 h after D-galactosamine/LPS administration [Glomerular filtration rate (GFR)₁, 0.79 ± 0.11 mL/min; GFR₂, 3.58 ± 0.49 mL/min·kgBW^-1; GFR₃, 0.39 ± 0.99 mL/min·gKW^-1]. The decreasing timing of GFR was consistent with that of the presence of hepatocyte necrosis and liver and kidney dysfunction.

CONCLUSION: The joint use of D-galactosamine and LPS can induce liver and kidney dysfunction and decline of glomerular filtration rate in rats which is a successful rat model of hepatorenal syndrome.

Severe hepatotoxicity and probable hepatorenal syndrome associated with sulfadiazine

PURPOSE. The case of a patient who developed hepatorenal syndrome during treatment with sulfadiazine for toxoplasmosis retinitis is reported.

SUMMARY

A 20-year-old Caucasian woman weighing 59 kg was admitted to the infectious diseases ward of a hospital in May 2009 with nausea, vomiting, and jaundice. In March 2009, she was diagnosed with toxoplasmosis retinitis and received sulfadiazine 3 g daily, pyrimethamine 50 mg daily, leucovorin 15 mg daily, and prednisolone 75 mg daily; she continued these medications for three weeks. After the development of gastrointestinal symptoms, she stopped taking the prescribed medications (five days before hospital admission). One day before hospital admission, her skin appeared jaundiced. At the time of admission, the patient had high transaminase levels, hyperbilirubinemia, abnormal prothrombin time and International Normalized Ratio values, and clinical evidence of acute fulminant hepatitis complicated by hepatorenal syndrome. Autoimmune hepatitis was excluded as a cause of her hepatotoxicity, as was Wilson's disease, herpes simplex virus, cytomegalovirus, hepatitis A virus, hepatitis E virus, and Epstein-Barr virus. She was diagnosed with probable drug-related fulminant hepatitis, presumably caused by sulfadiazine treatment. Lactulose 20 g was started for the prevention of encephalopathy. She received phytonadione 10 mg daily for three consecutive days, ranitidine 50 mg thrice daily, ciprofloxacin 250 mg twice daily, and acetylcysteine 600 mg thrice daily. The patient underwent hemodialysis five times during her hospital stay. Her symptoms gradually improved, and she was discharged on hospital day 20.

CONCLUSION

Probable hepatorenal syndrome requiring hemodialysis occurred in a patient receiving sulfadiazine for the treatment of toxoplasmosis retinitis.

[Race of experimental animals and development of renal failure in animal model of hepatorenal syndrome]

Hepatorenal syndrome (HRS) is still one of the most important challenges of medicine in 21st century. In spite of many years of experimental and clinical studies, it failed to discover precise pathomechanisms leading from hepatic damage to functional renal failure. Among many kinds and currents, experimental studies still play great role. There are few reported animal models of HRS, among them a rat model induced by galactosamine (GalN). In this model acute renal failure develops typically after hepatic damage.

AIM OF THE STUDY

We tried to test, whether in this model different breeds might develop typical HRS in the same way.

MATERIAL AND METHODS

We used 24 male Wistar and 16 Sprague-Dawley rats to achieve HRS by intraperitoneal injection of Ga1N. RESULTS. Liver failure with significant increase in serum concentration of bilirubin, alanine transaminase (ALT) and ammonia, as well as huge microscopic necrosis of hepatocytes developed in both groups, but we did not achieved any evidence of acute renal failure in Wistar rats group. Nevertheless, we found typical biochemical evidence of renal failure in Sprague-Dawley group.

CONCLUSION

We conclude, that opposite to Sprague-Dawley model, the Wistar rat model does not develop functional renal failure typical for HRS, probably because of some congenital, genetic predispositions.

[Role of nitric oxide system in pathogenesis of experimental model of hepatorenal syndrome]

Hepatorenal syndrome (HRS) is still one of a few great secrets of today's medicine. Pathomechanism of this syndrome, specially in case of an acute liver damage, is still poorly understood.

AIM OF THE STUDY

In our study in experimental galactosamine (Ga1N) model, using the nitric oxide synthase (NOS) inhibitor- N omega-nitro-L-Arginine (L-NAME), we tried to explain, whether the nitric oxide plays some role in this model of HRS.

MATERIAL AND METHODS

We used 56 male Sprague-Dawley rats (SDR) divided into 7 groups. To achieve acute renal failure in all tested groups of animals GalN was given intraperitoneally. To determine influence of nitric oxide inhibition, L-NAME was given before and after Ga1N injection. Control groups received adequate volume of 0.9% saline solution.

RESULTS

Liver and renal failure developed in all tested groups. Inhibition of NOS significantly but dose independently prevented the development of acute renal failure both before and after Ga1N injection. Pretreatment with L-NAME was significantly more succesful than post Ga1N treatment.

CONCLUSION

Our study showed that inhibition of nitric oxide synthase prevents the development of renal failure in animal model of HRS. This is probably the first observation that nitric oxide plays important role in this model of HRS.

[Effect of nephrophyte on the course of the hepatorenal syndrome caused by a complex of antituberculous drugs]

A complex of antituberculous drugs causes the hepatorenal syndrome in albino rats. The course administration of the plant agent nephrophyte in an experimental therapeutic dose during tuberculostatic therapy has a positive effect on the course of the hepatorenal syndrome.

[Hepatorenal syndrome: from physiopathology to treatment]

OBJECTIVES

Data synthesis on physiopathology and treatment of hepatorenal syndrome (HRS).

DATA SOURCES

Data were searched in the Medline database from 1975 to 2002 using the following key-words: hepatorenal syndrome, ascite, cirrhosis and portal hypertension.

DATA EXTRACTION

Publications from 1986 to 2002 were selected depending on the quality of their methodology and their pertinence. One publication from 1975 was kept.

DATA SYNTHESIS

Hepatorenal syndrome is a common and severe complication of patients with advanced liver cirrhosis with ascites. It is a functional renal failure due to intense vasoconstriction of the renal circulation secondary to an intense splanchnic vasodilatation. Two types of HRS are differentiated mainly by the speed and the magnitude of the renal failure. Liver transplantation remains the best treatment but is rarely applicable because of the short survival after diagnosis. In the last few years, new therapy have been developed, vasoconstrictor drugs which mainly elicit their effects on the splanchnic circulation as vasopressin and principally its analogues ornipressine and terlipressine are effective in improving renal function and could act as bridge for liver transplantation. The place of the transjugular intrahepatic portosystemic shunt remain to be evaluated.

CONCLUSION

Prognosis of patients with HRS remains poor but the pharmacologic treatment by terlipressine has improved the prognosis particularly in order to wait liver transplantation.

The isoprostanes: their quantification as an index of oxidant stress status in vivo

The F2 isoprostanes are a unique series of prostaglandinlike compounds formed in vivo from the free-radical-catalyzed peroxidation of arachidonic acid independent of the cyclooxygenase enzyme. The purpose of this review is to briefly summarize the status of our current knowledge regarding the isoprostanes. Novel aspects related to the biochemistry of isoprostane formation and methods by which these compounds are analyzed are discussed. The utility of measuring F2 isoprostanes as markers of lipid peroxidation in animal models of oxidant stress are then outlined. Finally, examples are provided in which quantification of isoprostanes have illuminated the role of oxidative injury in several human diseases.

Fatal acute hepatorenal failure following potassium permanganate ingestion

Potassium permanganate (KMnO4), a powerful oxidizing agent, is readily available without prescription. Tissue contact produces coagulation necrosis and the lethal consequences of oral ingestion are well described, with most deaths because of airway oedema and obstruction or circulatory collapse. Whilst systemic toxicity is reported, its mechanism is unclear. We describe a case of suicidal ingestion of KMnO4 followed by acute hepatorenal toxicity resulting in the death of the patient. The clinical course bore close resemblance to that of severe paracetamol overdose. We discuss the pathogenesis of the systemic toxicity of KMnO4 and postulate that it is due to oxidative injury from free radicals generated by the absorbed permanganate ion. We recommend that N-acetyl cysteine be given within the first few hours to all patients with potassium permanganate poisoning.

[Acute hepatorenal failure occurring after taking rifampicin]

A case of acute hepato-renal failure which developed after the oral intake of rifampicin is reported. Allergic reaction on the drug was accompanied by chill, weakness, paraesthesia, skin itch and facial swelling. The case described in the article appears to be all the more interesting due to the fact that severe lethal complication has developed in patient who had a history of allergic reactions on rifampicin.

[Captopril-induced toxic hepatitis]

Captopril, the competitive inhibitor of angiotensin-converting enzyme, has proved efficient in the treatment of arterial hypertension and heart failure. Its use is generally associated with low incidence of adverse reactions and hepatic injury has not been emphasized as an important adverse reaction in Denmark. However worldwide, several cases of hepatic injury have been reported. We report one case of Captopril-induced hepatic injury. Despite discontinuation of Captopril a hepatorenal syndrome developed and the patient died five weeks after admission. This report emphasizes the need to be aware of the possibility of hepatic injury in patients receiving Captopril.