Terlipressin versus midodrine plus octreotide for hepatorenal sy-ndrome-acute kidney injury: A propensity score-matched comparison

Objectives

Evidence on the comparison of treatments for hepatorenal syndrome-acute kidney injury (HRS-AKI) in a US population is limited. An indirect comparison of terlipressin plus albumin versus midodrine and octreotide plus albumin (MO) may provide further insight into treatment efficacy.

Methods

Cohorts of patients treated for HRS-AKI characterized by serum creatinine [SCr] < 5 mg/dL, baseline acute-on-chronic liver failure (ACLF) grades 0-2, and exclusion of patients listed for transplant if MELD ≥ 35 were pooled from 1) the CONFIRM and REVERSE randomized controlled trials (N=159 meeting eligibility criteria from N=216 overall treated with terlipressin) and 2) a retrospective review of medical records from 10 US tertiary hospitals (2016-2019; N=55 treated with MO meeting eligibility criteria from N=200 overall). The primary endpoint comparing the two cohorts was HRS reversal defined as achieving SCr ≤1.5 mg/dL at least once during the treatment. Covariate balancing propensity scoring was used to adjust for differences in baseline characteristics.

Results

HRS-AKI reversal was achieved in 52.35% of terlipressin-treated patientscompared to 20% of MO-treated patients [adjusted mean difference (95% confidence interval)= 32.35% (17.40, 47.30), p<.0001]. Terlipressin patients had increased overall survival (adjusted HR=0.57 (0.35,0.93), p=0.02) but similar transplant-free survival (adjusted HR= 0.79 (0.53,1.17), p=0.24). Achievement of HRS-AKI reversal was associated with increased OS and TFS regardless of treatment (p <0.001).

Conclusions

Consistent with prior reports, terlipressin plus albumin is more effective in improving kidney function and achieving HRS-AKI reversal than MO plus albumin based on indirect comparison in a US population.