Department of Internal Medicine, McMaster University, Hamilton, ON, Canada.
Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Crit Care Med. 2022 Oct 1;50(10):1419-1429. doi: 10.1097/CCM.0000000000005595. Epub 2022 Sep 12.
Hepatorenal syndrome (HRS) is associated with high rates of morbidity and mortality. Evidence examining commonly used drug treatments remains uncertain. We assessed the comparative effectiveness of inpatient treatments for HRS by performing a network meta-analysis of randomized clinical trials (RCTs).
We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Medline In-Process & Other Non-Indexed Citations, Scopus, and Web of Science from inception.
Pairs of reviewers independently identified eligible RCTs that enrolled patients with type 1 or 2 HRS. Pairs of reviewers independently extracted data.
We assessed risk of bias using the Cochrane tool for RCTs and certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach. Our main outcomes are all-cause mortality, HRS reversal, and serious adverse events. Of 3,079 citations, we included 26 RCTs examining 1,736 patients. Based on pooled analysis, terlipressin increases HRS reversal compared with placebo (142 reversals per 1,000 [95% CI, >87.7 to >210.9]; high certainty). Norepinephrine (112.7 reversals per 1,000 [95% CI, 52.6 to >192.3]) may increase HRS reversal compared with placebo (low certainty). The effect of midodrine+octreotide (67.8 reversals per 1,000 [95% CI, <2.8 to >177.4]; very low) on HRS reversal is uncertain. Terlipressin may reduce mortality compared with placebo (93.7 fewer deaths [95% CI, 168.7 to <12.5]; low certainty). Terlipressin probably increases the risk of serious adverse events compared with placebo (20.4 more events per 1,000 [95% CI, <5.1 to >51]; moderate certainty).
Terlipressin increases HRS reversal compared with placebo. Terlipressin may reduce mortality. Until access to terlipressin improves, initial norepinephrine administration may be more appropriate than initial trial with midodrine+octreotide. Our review has the potential to inform future guideline and practice in the treatment of HRS.
肝肾综合征（HRS）与高发病率和死亡率相关。用于评估常用药物治疗效果的证据仍不确定。我们通过对随机临床试验（RCT）的网络荟萃分析来评估 HRS 的住院治疗的相对疗效。
我们从开始就检索了 MEDLINE、Embase、Cochrane 对照试验中心注册库、Medline 在处理和其他非索引引用、Scopus 和 Web of Science。
pairs of reviewers 独立确定了纳入患有 1 型或 2 型 HRS 的患者的合格 RCT。pairs of reviewers 独立提取数据。
我们使用 Cochrane 对 RCT 的工具评估偏倚风险，并使用 Grading of Recommendations, Assessment, Development and Evaluations 方法评估证据的确定性。我们的主要结局是全因死亡率、HRS 逆转和严重不良事件。在 3079 条引文，我们纳入了 26 项 RCT 研究，共纳入了 1736 名患者。基于汇总分析，特利加压素与安慰剂相比增加 HRS 逆转（每 1000 人中有 142 例逆转[95%CI，>87.7 至 >210.9]；高确定性）。去甲肾上腺素（每 1000 人中有 112.7 例逆转[95%CI，52.6 至 >192.3]）可能比安慰剂增加 HRS 逆转（低确定性）。米多君+奥曲肽（每 1000 人中有 67.8 例逆转[95%CI，<2.8 至 >177.4]；非常低）对 HRS 逆转的效果不确定。与安慰剂相比，特利加压素可能降低死亡率（每 1000 人中有 93.7 例死亡减少[95%CI，168.7 至 <12.5]；低确定性）。与安慰剂相比，特利加压素可能增加严重不良事件的风险（每 1000 人中有 20.4 例事件增加[95%CI，<5.1 至 >51]；中等确定性）。
特利加压素与安慰剂相比增加 HRS 逆转。特利加压素可能降低死亡率。在获得特利加压素之前，最初给予去甲肾上腺素可能比最初试用米多君+奥曲肽更合适。我们的综述有可能为 HRS 治疗的未来指南和实践提供信息。
