Análise dos resultados do tratamento da terlipressina na síndrome hepatorrenal

Abstract

Hepatorenal syndrome (HRS) is a potentially reversible functional acute renal failure in patients with advanced cirrhosis, with a high mortality rate, resulting from hemodynamic changes that promote renal vasoconstriction. HRS is subdivided into 2 types: type 1 - rapid progressive renal failure and lower survival rate (15 days) and type 2 - slowly and more progressive functional disease. The definitive treatment is liver transplantation, and there are few first-line therapeutic options for HRS type 1 - a bridging option - including terlipressin, which is not offered by Brazilian public health system. Aim: to evaluate the efficacy and safety of terlipressin in the HRS type 1 cirrhotic patients, admitted to tertiary care center University Hospital. Patients and methods: Adults patients with cirrhosis and HRS type 1 IAC criteria 2007 were included. A 30-month prospective study that was part of a Brazilian public health system research project (PPSUS/FAPESP). Eligibility criteria: age 18-75 years, liver cirrhosis as diagnosed by liver biopsy or clinical absence of neoplasms (except hepato-cellular within Milan criteria), possibility of further treatment (Liver Transplantation and/or TIPS), informed consentiment signature, any contraindication to terlipressin as: coronary insufficiency, severe peripheral vascular insufficiency and cardiac arrhythmias. Results: 303 AKI episodes were identified in 161 patients and 22 HRS-1 episodes occurred in 19 patients: 57.4±7 years; 12 (63.2%) men; 10 (52.6%) alcoholic cirrhosis, 4 (21.1%) NASH, 2 (10.5%) HCV, 2 (10.5%) alcohol and NASH. 13 events (59.1%) CPT C, 9 events (40.9%) B and MELD score 23.5 (17-39). Infection - 18 events (81.8%): 8 (44.4%) Urinary tract infection; 5 (27.8%) SBP; 2 (11.1%) bacterioascite. Mean creatinine at diagnosis 3.40 (±0.64); FE Na +0.12 (0.02-3.66) and FE urea 23.94 (±14.08). Twenty episodes were treated with terlipressin and albumin for 6.2 days (1-14). Only 1 patient presented moderate adverse event to terlipressin (diarrhea and hydroelectrolytic disorders) resolved after the suspension; 8 patients required adjustment of albumin by pulmonary edema. Complete response defined by cr<1.5mg/dL at any time of treatment occurred in 11 events (55%), partial response 3 events (15%) and absence of response in 6 events (30%). Three patients presented recurrence of HRS-1 were treated again with terlipressin and albumin. Secondary outcomes: 4 underwent liver transplantation and 4 dialysis. Mortality was 73.7% (14/19), 11 patients died septic shock and 3 patients were hypovolemic shock. Conclusion: Terlipressin was effective, safe and well tolerated. There was a response in most patients, but a high mortality, confirming the severity of HRS-1 in advanced cirrhotic patients. Our results in daily practice, similar to the literature, corroborate the use of this resource in brazilian public health system, especially as it is the most cost-effective resource.