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Hepatorenal syndrome journal
This systematic review and network meta-analysis compared the efficacy of different drug treatments for type 1 hepatorenal syndrome. The analysis included 13 randomized controlled trials comparing terlipressin to placebo or other drugs like norepinephrine. The results showed moderate evidence that terlipressin may reduce short-term mortality compared to placebo. Terlipressin and norepinephrine were both found to be more effective at reversing hepatorenal syndrome compared to midodrine plus octreotide. However, the evidence was limited by the small sizes and short follow-ups of the included studies. Larger, higher quality trials are still needed to evaluate the real-world effectiveness and safety of terlipressin for treating type 1 hepatorenal
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Hepatorenal syndrome journal
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- 2. Facciorusso A. etal Lancet Gastroenterol Hepatol 2016 December 1, 2016
- 3. INTRODUCTION Type 1 hepatorenalsyndrome: is a functional, potentially reversible, form of acute kidney injury caused by haemodynamic imbalances in end-stage liver disease is a life-threatening complication of decompensated liver cirrhosis Mortality > 80% at 3 months and median survival < 4 weeks. Few data exist for the comparative efficacy of the drugs, particularly in improving survival. Pressing need for effective pharmacological treatments to improve survival and reverse HRS.
- 4. AIM To comparethe efficacy of different management strategies for type 1 hepatorenal syndrome.
- 5. STUDY DESIGN Systematic reviewand network meta-analysis
- 6. INCLUSION CRITERIA RCTs Age > 18 yrs Decompensated cirrhosis and type 1 hepatorenal syndrome Albumin recipient as treatment
- 7. EXCLUSION CRITERIA Studies Observationalstudies Trials exclusively of patients with type 2 HRS Trials comparing different routes of therapy of same drug Cross-over trials without washout period, and Trials of experimental, unapproved therapies Patients With active infection
- 8. OUTCOMES Primary outcome: • Reductionin short-term mortality Secondary outcomes: Reversal of HRS (defined as decrease of sr. creatinine level ≤ 1.5 mg/dL) Recurrence of HRS after initial reversal, and Incidence of treatment-related adverse events
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- 10. For thissystematic review and network meta-analysis, they searched MEDLINE In-Process & Other Non- Indexed Citations, Embase, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science for papers published up to June 9, 2016. They did pairwise and network meta-analyses to produce odds ratios (ORs) and 95% CIs. We used the GRADE criteria to appraise quality of evidence.
- 12. All trials weretwo-arm controlled trials– i) six compared terlipressin with placebo, ii) four compared terlipressin with nor adrenaline, iii) one compared terlipressin with midodrine plus octreotide, iv) one compared terlipressin with dopamine plus furosemide, v) and one compared noradrenaline with midodrine plus octreotide.
- 16. Pairwise meta-analysis ofdrugs efficacy to reduce mortality (A)
- 17. Pairwise meta-analysis ofdrugs efficacy to reverse hepatorenal syndrome (B)
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- 19. Moderate-quality evidencemight support the use of Terlipressin over Placebo for reduction of short-term mortality (OR 0·65, 95% CI 0·41–1·05). Low-quality evidence supported the use of Noradrenaline, Midodrine + Octreotide, and Dopamine plus furosemide over Placebo to reduce mortality. No Odds ratio for any of the comparisons versus placebo were significant.
- 20. Moderate-quality evidencesupported the use of Terlipressin over Midodrine + Octreotide (OR 26·25, 95% CI 3·07–224·21) to reverse HRS. Low-quality evidence supported the use of Noradrenaline over Placebo (4·17, 1·37–12·50) and over Midodrine + Octreotide (10·00, 1·49–50·00) for this outcome. A median of 16% (range 5–20) of Terlipressin-treated patients, and 33% (range 6–40) Noradrenaline-treated patients with reversal of HRS had recurrence on discontinuation of therapy.
- 21. A medianof 8% (range 4–22) Terlipressin-treated patients required discontinuation of therapy due to serious adverse events.
- 22. STRENGTH First networkmeta-analysis of all drug interventions for type 1 HRS to reduce mortality.
- 23. LIMITATIONS Paucity ofdirect head-to-head comparative trials Trials were generally small with low event rates Network meta analyses limitations Most studies had a small sample size and a short follow-up Treatment-related adverse events were poorly reported
- 24. CONCLUSION Terlipressin withalbumin might reduce short-term mortality compared with Placebo in patients with type 1 HRS. Terlipressin with albumin and Noradrenaline with albumin are both superior to Midodrine plus octreotide with albumin for reversal of HRS. Future pragmatic clinical trials of Terlipressin with albumin are warranted to evaluate real-world eff ectiveness and safety in patients with type 1 HRS.
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