1 Norepinephrine Infusion for Treatment of Type 1 Hepatorenal Syndrome

Abstract

NOREPINEPHRINE INFUSION FOR TREATMENT OF TYPE 1 HEPATORENAL SYNDROME Sabeen Abid, Nauman Shahid, David Sass, Kenneth Rothstein, David Reich, Karthik Ranganna , Ziauddin Ahmed. Drexel University College of Medicine, Philadelphia PA Hepatorenal syndrome Type 1 (HRS-1) is a complication of advanced liver cirrhosis associated with high mortality and a median survival of 2 weeks. Treatment of HRS-1 and reversal of the underlying pathophysiology is extremely important for patients awaiting liver transplantation (OLT). Terlipressin is the treatment of choice for type 1 HRS but it is expensive and not approved by FDA. Norepinephrine (NE) has been shown to be equally effective and safe in two RCT. We report a case of 27 year old white male with Child’s C cirrhosis who was listed for OLT. His disease was complicated by refractory ascites and HRS type 2 at baseline. He was admitted for an acute change in mental status with a MELD score of 30 and serum creatinine (Scr) of 1.9 mg/dl. The Scr continued to rise to 2.7 mg/dl by hospital day 7 despite adequate volume expansion with normal saline and albumin. A diagnosis of HRS-1 was made after carefully ruling out other causes of renal dysfunction. A combination of octreotide and midodrine was initiated however the patient failed to respond with a continued rise in Scr to 3.5 mg/dl by day 11. At this point the above therapy was discontinued and an infusion of NE was started at 10 mcg/hr. Within 48 hours his urine output increased from 1445 ml on day 0 to 3575 ml on day 1and 3725 ml on day two, Scr decreased from 3.5 mg/dl to 2.8 mg/dl at day 2. The patient tolerated the infusion well. At this time a liver became available and the patient underwent a successful OLT. At a recent follow up visit, 9 months post OLT, the patient had a stable Scr of 1.0 mg/dl. Infusion of NE can be an effective treatment of HRS-1. It should be considered as a primary therapy in patients whom are awaiting OLT due to its availability, cost and comparable efficacy to Terlipressin.