Norepinephrine useful rescue therapy in hepatorenal syndrome in non ICU setting: Study

Vasoconstrictors are the treatment of choice for the hepatorenal syndrome (HRS).

A group of researchers from U.S.A evaluated the real-life effectiveness of a sequential vasoconstrictor regimen of midodrine–octreotide followed by norepinephrine in a nonintensive care unit (non-ICU) setting in the United States, where terlipressin is not available.

The diagnosis of hepatorenal syndrome (HRS) and definitions of response to therapy was based on 2015 guidelines from the International Club of Ascites. In adult patients with HRS without partial or full response to oral midodrine and subcutaneous octreotide,norepinephrine was administered at a starting dose of 5 mcg/minute, with a goal to achieve a mean arterial pressure (MAP) of 10 mm Hg above baseline. The researchers assessed predictors of response and treatment outcomes.

The results of the study are as follows:

A total of 61 patients were administered midodrine and octreotide for the treatment of HRS, with a 28% response rate.

The median MELD-Na (Model for End-Stage Liver Disease–sodium) the score was 30.

Responders were more likely to have alcohol-related liver disease and lower Acute-on-Chronic Liver Failure (ACLF) grade.

Of the non-responders, 20 were then administered norepinephrine, of whom 45% achieved full or partial response.

Achieving a MAP increase of ≥10 mm Hg was associated with a greater probability of response.

Patients who responded to norepinephrine experienced improved transplant-free survival at 90 days; 5 of 20 patients experienced norepinephrine treatment-related adverse events, namely arrhythmias.

Thus, the researchers concluded that norepinephrine can be effectively used in a non-ICU setting as rescue therapy in patients who have not responded to midodrine and octreotide. Based on these data, we propose a practical stepwise algorithm for vasoconstrictor therapy to manage HRS in situations where terlipressin is not an option.

Reference:

Feasibility and Effectiveness of Norepinephrine Outside the Intensive Care Setting for Treatment of Hepatorenal Syndrome by Kwong A et. al. published in the AASLD.

https://doi.org/10.1002/lt.26065