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Abstract Details
Responsiveness to Vasoconstrictor Therapy in Hepatorenal Syndrome Type 1
Kidney360. 2023 Jan 10. doi: 10.34067/KID.0000000000000068. Online ahead of print.
1Department of Nephrology, Ochsner Health, New Orleans, LA, USA.
2Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia.
3HRS-HARMONY Consortium.
4Division of Nephrology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR.
5Multiorgan Transplant Institute, Ochsner Health, New Orleans, LA, USA.
6Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
7Division of Nephrology, Department of Medicine, Yale University, New Haven, CT, USA.
8Veterans Affairs Connecticut Healthcare, West Haven, CT, USA.
9Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.
10Department of Pulmonary and Critical Care Medicine, Ochsner Health, New Orleans, LA, USA.
Abstract
Background: Raising mean arterial pressure (MAP) during treatment of hepatorenal syndrome type 1 (HRS-1) with vasoconstrictors is associated with renal recovery. However, the optimal MAP target and factors associated with response to vasoconstrictors remain unclear.
Methods: Records from hospitalized patients with HRS-1 treated with vasoconstrictors without shock were reviewed searching for those who achieved ≥5 mmHg rise in MAP within 48 hours. We examined the relationship between the mean MAP achieved during the first 48-72 hours of vasoconstrictor therapy and the change in serum creatinine (sCr) up to day 14. Endpoints were >30% reduction in sCr without need for dialysis or death by day 14 (primary) or by day 30 (secondary).
Results: Seventy-seven patients with HRS-1 treated for 2-10 days with either norepinephrine (n=49) or midodrine/octreotide (n=28) were included. Median age was 52 (IQR 46-60), 40% were female and 48% had alcoholic cirrhosis. At vasoconstrictor initiation, median MAP was 70 mmHg (IQR 66-73) and median sCr was 3.8 mg/dL (IQR 2.6-4.9). When analyzed by tertiles of mean MAP increment (5-9, 10-14, ≥15 mmHg), there was greater reduction in sCr with greater rise in MAP (ANOVA for trend, p<0.0001). By multivariate logistic regression analysis, mean MAP rise during the first 48-72 hrs [OR 1.15 (1.02 - 1.299), p=0.025], norepinephrine as vasoconstrictor [OR 5.46 (1.36-21.86), p=0.017] and baseline sCr [OR 0.63 (0.41-0.97), p=0.034] were associated with the primary endpoint; whereas mean MAP rise during the first 48-72 hrs [OR 1.17 (1.04-1.33), p=0.012] and baseline sCr [OR 0.63 (0.39-0.98), p=0.043] were associated with the secondary endpoint.
Conclusion: Greater magnitude of rise in MAP with vasoconstrictor therapy in HRS-1, lower baseline sCr, and use of norepinephrine over midodrine/octreotide are associated with kidney recovery. Targeting an increment of MAP ≥15 mmHg may lead to favorable renal outcomes.
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