الفهرس 
Hepatorenal syndrome (HRS)Only 14 pages are availabe for public view
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Abstract
Abstract
Hepatorenal syndrome (HRS) is a potentially reversible clinical syndrome, which is characterized by functional renal failure in end-stage liver disease.
Management of HRS is based on therapy with vasoconstrictors and albumin. Terlipressin is a drug of choice particularly in type 1 HRS. However, terlipressin is not readily available in several countries and the therapy is expensive. Noradrenaline, a catecholamine with predominantly alpha-adrenergic activity is widely available and is relatively inexpensive. Noradrenaline has shown encouraging results in circulatory dysfunction and type 1 HRS.
The aim of the study is to compare between the effect of Terlipressin and norepinephrine in the management of type I hepatorenal syndrome.
This study comprised 40 patients with Type I hepatorenal syndrome admitted during the period of research from February 2019 to July 2019 to Ain Shams University hospitals.
All patients have acute or chronic liver diseases with type I hepatorenal syndrome, and the patients were divided into two groups:
20 patients with type I hepato-renal syndrome who received terlipressin and 20 patients with type I hepato-renal syndrome who received norepinephrine.
Results of the current study revealed that mean age of patients in both groups I and II was 53.1±4.14, and 52.1±6.63 years respectively. There was no statistically significant difference between both studied groups regarding to age (P=0.571). Also, studied patients showed a high percentage of males in both studied groups (55%&65& respectively) but without statistically significant different between different groups (P>0.05).
In this study, There was no statistically significant difference between number of cases regarding presence of hypertension, cellulitis, pneumonia, SBP, and UTI in both studied groups (P>0.05)
As regard the results of haematological parameters, the results of this study showed that the mean value ± SD for the red blood cells (RBCs) count was 3.84±0.89, 3.62± 0.64)(106/µL), the hemoglobin (10.05± 1.78, 10.21 ± 1.82)(g/dL), the platelets count and the white blood cells (WBCs) count (137.7 ± 60.39, 160.37 ± 101.68), and (12.139 ± 4.79, 12.88 ± 6.19) (103/µL) in terlipressin & norepinephrine group respectively, with no significant difference between two studied groups (P>0.05).
The variation in routine clinical investigations of liver function among different groups was not statistically significant. Both groups showed marked increase in ALT (103.6 ±71.36, and 81.05± 54.1), AST levels (116.7± 114.83 and 107.3 ± 76.01), bilirubin & INR levels than their normal levels and decrease in serum albumin levels [2.17 ± 0.41 g/dl&1.96 ± 0.48 g/dl] in group I &II respectively.
At baseline there was no difference between the studied groups regarding kidney function as it was all worse moreover urine output and MAP for all cases was decreased (P>0.05).The mean creatinine level (before starting treatment) was 3.18 mg/dl and3.22 mg/dl, the mean urea level was 113.9± 60.33 mg/dl & 120.9 ± 49.5 mg/dl, the mean serum NA level was 117.7± 11.27 and 120.65 ± 9.69, and the mean urine output was 435 ± 228.9 and 517.5 ± 253.54 in both groups; respectively. Moreover, the mean arterial pressure was similar in both studied groups at the beginning of study. It was 81.6 ± 8.98 and 83.9 ± 9.19 in both terlipressin and norepinephrine groups; respectively.
After 3 days of treatment, the mean serum creatinine lowered in terlipressin group than initial creatinine level {2.94±1.27 vs. 3.18 ±1.26 (mg/dL)}, but without significant difference (P = 0.16). While in noradrenaline group a slight increment in creatinine levels was detected after three days of treatment {3.43±1.4 vs. 3.22±0.99 (mg/dL)} (P=0.244). This is due to increase number of non-responder in this group; 4 patients died after 2 days and 5 patients showed no response to treatment. Moreover, urine output and MAP were increased in both groups. There were {505.26 ± 240.31 (mL/24h) & 82.79±10.17 (mmHg)} in terlipressin group compared to {521.88 ±210.53 (ml/24h) & 82.38± 8.89(mmHg)} in norepinephrine group. There was no significant difference between 2 studied groups regarding urine output and MAP (P=0.831 & 0.9). Also, both parameters showed slight increase after 3 days than that detected at baseline. In terlipressin group urine output and MAP after 3 days were {505.26 ± 240.31 (ml/24h) & 82.79±10.17 (mmHg)} compared to {435± 228.89 (mL/24h), and 81.6±8.98 (mmHg)} at the beginning of study (P= 0.001 & P=0.254 respectively). In addition, similar results were detected in patients who received norepinephrine as urine output and MAP after 3 days of treatment were {521.88 ±210.53 (mL/24h) & 82.38± 8.89 (mmHg)} compared to {517.5± 253.5 (mL24h), and 83.9±9.19 (mmHg)} at the beginning of study (P=0.860 & P=0.423; respectively).
After 5 days, mean values of serum creatinine, urine output, and MAP were {2.74±1.57 (mg/dl), 537.5±325.3 (mL/24h), and 85.25±14.67 (mmHg)} in group I vs. {2.87±1.48 (mg/dl), 600±252.26 (mL/24h), and 85.33±10.04 (mmHg)} in group II with P values of 0.827, 0.586, and 0.987; respectively between the two studied groups. After 5 days of treatment, patients in terlipressin group had mean creatinine level 2.74±1.57 (mg/dl) compared to 2.94±1.27 (mg/dL) after 3 days (P=0.721). In addition, mean creatinine level decreased in the norepinephrine group after 5 days to reach 2.87±1.48 (mg/dL) compared to 3.43±1.4 (mg/dl) after 3 days (P=0.899) Furthermore, both drugs caused a non- significant increase in urine flow, and MAP in patients with AKI-HRS than that detected at 3 days but without significant difference (P=0.315 and 0.271) for group I and (P= 0.828 and 0.618) for group II.
After 7 days, mean creatinine levels, urine output, and MAP were 2.45±2.3 (mg/dL), 616.67±294.13 (mL/24h), and 90.182±12.28 (mmHg) in group I & 2.3±1.48 (mg/dL), 694.44± 246.78 (mL/24h), and 90±12.5 (mmHg) in group II; with P values of 0.854, 0.529, and 0.974 respectively between the two studied groups. The terlipressin group recorded lower serum creatinine level after 7 days of treatment {2.45±2.3(mg/dL)} compared to that detected after 5 days {2.74±1.57(mg/dL)}, but without significant difference (P=0.787). Also, patients receiving norepinephrine showed similar response as creatinine levels were decreased after 7 days of treatment {2.3±1.48(mg/dL)} compared to that detected after 5 days {2.87±1.48(mg/dL)} with p-value =0.224.In the terlipressin group, urine output rate increased from 537.5±325.3 to 616.67±294.13 (mL/24h) (P =0.212) and in the norepinephrine group from 600±252.26 to 694.44± 246.78 mL/24h (P=0.06).Also, MAP elevated from 85.25±14.67 (mmHg) to 90.182±12.28 (mmHg) in the terlipressin group, P= 0.894 and from 85.33±10.04 (mmHg) to 90±12.5 (mmHg) in norepinephrine group (P=0.161).
Overall, out of 40 patients included in this study, 8 patients (40%) in group I and 11 (55%) of group II did not respond to treatment and died during the first week of study. At the end of this study, 55% (11/20) of patients in the terlipressin group and 45% (9/20) of those in the norepinephrine group responded to vasoconstrictor therapy, and their HRS reverted. The survival rates at the end of study were comparable in the two groups: 55% (11/20) in the terlipressin group versus 45% (9/20) in the norepinephrine group.
In both groups, there was a progressive significant decrease in serum creatinine levels at the end of study than that detected after 7 days of treatment P=0.023 and 0.001 in group I and II; respectively. Compared to norepinephrine group, terlipressin group achieved higher increase in urine/24h at the end of study from baseline. However, both drugs caused a significant increase in urine flow in patients with AKI-HRS from baseline. In terlipressin group different in urine output at the end of study from that after one week of study was significant (P=0.024) Also, MAP show the same trend (P=0.009). Similar observation was also noticed in the norepinephrine group as urine output and MAP at the end of study showed significant increase than that detected after one week of study (P=0.006 & P=0.032 for the two parameters respectively