Ong Nicodemus, Wong Florence
Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Gastroenterol Hepatol (N Y). 2025 Aug;21(8):519-527.
The use of terlipressin in the treatment of hepatorenal syndrome type 1 (HRS-1) in patients with advanced cirrhosis wait-listed for liver transplant (LT) has been controversial. Successful treatment lowers patients' Model for End-Stage Liver Disease (MELD) score and hence their LT priority. Terlipressin's potential ischemic side effects and risks for respiratory failure in susceptible patients lend support to directly proceed to LT. However, responders to terlipressin have better post-LT survival with lower incidences of post-LT chronic kidney disease and need for renal replacement therapy (RRT). Available data suggest that terlipressin responders have not all been impacted negatively. HRS-1 itself confers a greater negative effect on survival when compared with patients with the same MELD score but without HRS-1; therefore, various countries except the United States have strategies to preserve the wait-list position of terlipressin responders. The MELD lock strategy uses the patient's pre-terlipressin MELD score to maintain their wait-list position indefinitely; a modified MELD lock system requires re-evaluation of the patient's eligibility status every 3 months. Patients taking long-term terlipressin for recurrent HRS are treated as needing RRT in assessing their LT priority. The United States considers that more data are needed before devising its own system for managing wait-listed terlipressin responders. Current data suggest that treating and reversing HRS in wait-listed patients is the appropriate course of action. This article will review the pros and cons of using terlipressin in LT wait-listed patients with HRS and the various strategies practiced by different countries to ensure equitable access to LT.
对于等待肝移植（LT）的晚期肝硬化患者，使用特利加压素治疗1型肝肾综合征（HRS-1）一直存在争议。成功的治疗会降低患者的终末期肝病模型（MELD）评分，从而降低其肝移植优先级。特利加压素潜在的缺血性副作用以及在易感患者中导致呼吸衰竭的风险，支持直接进行肝移植。然而，对特利加压素治疗有反应的患者肝移植后生存率更高，肝移植后慢性肾病的发生率更低，且需要肾脏替代治疗（RRT）的需求也更低。现有数据表明，对特利加压素治疗有反应的患者并非都受到了负面影响。与具有相同MELD评分但无HRS-1的患者相比，HRS-1本身对生存率的负面影响更大；因此，除美国外，各国都有策略来保留对特利加压素治疗有反应患者在等待名单上的位置。MELD锁定策略使用患者在使用特利加压素前的MELD评分来无限期维持其在等待名单上的位置；改良的MELD锁定系统要求每3个月重新评估患者的资格状态。在评估肝移植优先级时，因复发性HRS而长期服用特利加压素的患者被视为需要肾脏替代治疗。美国认为在设计自己的系统来管理等待名单上对特利加压素治疗有反应的患者之前，还需要更多数据。目前的数据表明，治疗并逆转等待名单上患者的HRS是合适的做法。本文将综述在等待肝移植的HRS患者中使用特利加压素的利弊，以及不同国家为确保公平获得肝移植而采取的各种策略。
