Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography

Background & Aims: Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefit, but may be associated with cardiopulmonary complications. We analysed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo), cardiac and renal biomarkers. Approach: Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6h of admission, at the time of starting terlipressin(48h), and at 72h. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic Cardiomyopathy(CCM) was defined per 2020 criteria. Results: One hundred and forty patients were enrolled [84% men, 59% alcohol-associated disease, mean MELDNa-25±standard deviation(SD) 5.6]. Median daily dose of infused terlipressin was 4.3(interquartile range:3.9-4.6)mg/day; mean duration-6.4± SD-1.9 days; complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cut-offs for prediction of terlipressin nonresponse were cardiac variables-[E/e'>12.5(indicating increased left filling pressures, C-statistic-0.774), e' velocity<7 cm/s (indicating impaired relaxation; C-statistic-0.791), >20.5% reduction in cardiac index at 72h(C-statistic-0.885); p<0.001] and pre-treatment biomarkers (Cystatin C>2.2 mg/l, C-statistic-0.640 and NT-ProBNP>350 pg/mL, C-statistic-0.655;p<0.050). About 6% of all HRS-AKI patients and 26% of patients with CCM had pulmonary edema. Presence of CCM(aHR1.9;CI-1.8-4.5,p=0.009) and terlipressin nonresponse (aHR 5.2;CI-2.2-12.2, p<0.001) were predictors of mortality independent of age, gender, obesity, DM-2, etiology and baseline creatinine Conclusions: Cirrhotic cardiomyopathy and reduction in cardiac index, reliably predict terlipressin non-response. CCM is independently associated with poor survival in HRS-AKI. Export