Author information

• ¹Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
• ²Divisions of Gastroenterology and Hepatology and Pulmonary and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
• ³Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.
• ⁴Divisions of Gastroenterology, Hepatology, Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.
• ⁵GI and Liver Unit, Institut de Malalties Digestives, Hospital Clínic, Barcelona, Spain. Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.

Abstract

Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a serious complication of severe liver disease with a clinically poor prognosis. Supportive care using vasoconstrictors and intravenous albumin are the current mainstays of therapy. Terlipressin is an efficacious vasoconstrictor that has been used for 2 decades as the first-line treatment for HRS-AKI in Europe and has demonstrated greater efficacy in improving renal function compared to placebo and other vasoconstrictors. One of the challenges associated with terlipressin use is monitoring and mitigating serious adverse events, specifically adverse respiratory events, which were noted in a subset of patients in the recently published CONFIRM trial, the largest randomized trial examining terlipressin use for HRS-AKI. In this article, we review terlipressin's pharmacology, hypothesize how its mechanism contributes to the risk of respiratory compromise and propose strategies that will decrease the frequency of these events by rationally selecting patients at lower risk for these events.