Nanda Arjun, Reddy Rewanth, Safraz Humaira, Salameh Habeeb, Singal Ashwani K
Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL.
Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX.
J Clin Gastroenterol. 2018 Apr;52(4):360-367. doi: 10.1097/MCG.0000000000000913.
Hepatorenal syndrome (HRS) is a serious complication of advanced chronic liver disease. Different pharmacological therapies have variable efficacy. We performed a systematic review and meta-analysis to compare the efficacy of various drugs in the treatment of HRS.
Randomized controlled trials comparing active drug with placebo or comparing 2 different drugs were included in this analysis. Primary study outcome was reversal of HRS. Secondary outcomes were HRS relapse and patient survival. Subgroup analysis was performed on patients with type 1 HRS.
Thirteen randomized controlled trial were eligible for analysis. Terlipressin plus albumin was more efficacious than placebo plus albumin (odds ratio=4.72; 95% confidence interval, 1.72-12.93; P=0.003) or midodrine plus albumin and octreotide (odds ratio=5.94; 95% confidence interval, 1.69-20.85; P=0.005), for HRS reversal. However, no significant difference was noted comparing terlipressin plus albumin versus noradrenaline plus albumin, octreotide plus albumin versus placebo plus albumin or noradrenaline plus albumin versus midodrine plus albumin and octreotide. None of the comparisons showed difference on HRS relapse or patient survival. Subgroup analysis revealed that terlipressin was more effective than placebo for type 1 HRS reversal, but no significant differences were noted between any other comparisons, and none of the comparisons showed difference on HRS relapse or patient survival.
Intravenous infusion of terlipressin is the most effective medical therapy for reversing HRS. Intravenous infusion of noradrenaline is an acceptable alternative. Studies are needed as basis for developing pharmacological strategies to reduce relapse of HRS and improve patient survival.
肝肾综合征（HRS）是晚期慢性肝病的一种严重并发症。不同的药物治疗疗效各异。我们进行了一项系统评价和荟萃分析，以比较各种药物治疗HRS的疗效。
本分析纳入了比较活性药物与安慰剂或比较两种不同药物的随机对照试验。主要研究结局是HRS的逆转。次要结局是HRS复发和患者生存。对1型HRS患者进行了亚组分析。
13项随机对照试验符合分析条件。特利加压素联合白蛋白在逆转HRS方面比安慰剂联合白蛋白（优势比=4.72；95%置信区间，1.72 - 12.93；P = 0.003）或米多君联合白蛋白和奥曲肽（优势比=5.94；95%置信区间，1.69 - 20.85；P = 0.005）更有效。然而，比较特利加压素联合白蛋白与去甲肾上腺素联合白蛋白、奥曲肽联合白蛋白与安慰剂联合白蛋白或去甲肾上腺素联合白蛋白与米多君联合白蛋白和奥曲肽时，未发现显著差异。在HRS复发或患者生存方面，所有比较均未显示出差异。亚组分析显示，特利加压素在逆转1型HRS方面比安慰剂更有效，但其他任何比较之间均未发现显著差异，且在HRS复发或患者生存方面，所有比较均未显示出差异。
静脉输注特利加压素是逆转HRS最有效的药物治疗方法。静脉输注去甲肾上腺素是一种可接受的替代方法。需要开展研究，为制定减少HRS复发和改善患者生存的药物策略提供依据。
