I am so excited for an exciting discussion! Big @LTxJournal journal club - the awesome @lizzieabymd (my SoMe partner in crime), my mentor and expert discussant @elizabeth_verna (DE), and superstar hepatologist @salvatore_piano (AE) (thread) https://twitter.com/GiJournal/status/1319648740374945792

In preparation for tonight’s discussion, I would like to give a little background.

Lesson 1: Listen to @ebtapper - go to pubmed, search the last article for your topic, and learn the history.

The use of terlipressin in HRS truly started in 1998 with a pilot study. A double-blind, cross-over randomized, placebo-controlled study in 9 patients showed increased GFR and UOP. https://www.sciencedirect.com/science/article/pii/S0168827898801517

A follow up 9 pt pilot study from Barcelona showed reversal of HRS in 7 of 9 pts. https://reader.elsevier.com/reader/sd/pii/S0168827800801580?token=BBF9D356D69A80ED89E39FAE0B07C97B7B6DC91FA82A06833127ECC52CA3CFABB8A66A4B2B1C8DC6677B7D6EEB239320

While we have used terlipressin, norepi, midodrine and octreotide, we have not made much progress in 20 years however in treating HRS-AKI. @mary_j_thompson @ebtapper @pummy92 @michiganliver
https://link.springer.com/article/10.1007%2Fs10620-019-05858-2

Terlipressin has been shown in several studies to better than midodrine-octreotide (70% vs. 28% improvement in kidney function). @salvatore_piano @hep_journal https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.27709

Here’s another study from the US in 2011 showing that terlipressin improves outcomes regardless of txp status but really may improve post-LT management via improved renal function. @ltxjournal https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/lt.22395

A @cochranecollab @CochraneLibrary review noted the potential benefits of terlipressin while acknowledging its adverse effects as well. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005162.pub4/full?cookiesEnabled

And finally, a systematic review and meta-analysis of 12 studies and 700 patients in @apandt showed similar findings to the @cochranelibrary review above.
https://onlinelibrary.wiley.com/doi/full/10.1111/apt.13912

So, terlipressin’s effectiveness in HRS is not really in question. But there are still some unanswered questions - stay with me here...

A major unanswered question (esp in US) is: Is terlipressin better than norepi? A pilot study from Italy ( @jhepatology https://www.sciencedirect.com/science/article/pii/S0168827812001031?via%3Dihub) and more data from India ( https://www.sciencedirect.com/science/article/pii/S0168827807002875?via%3Dihub) show no difference in effectiveness.

A meta-analysis from 4 studies shows norepi may be an attractive alternative to terlipressin due to less adverse effects with similar efficacy - but this was limited to 4 studies @plosone. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0107466

The most recent update to this literature comes from India where it was noted that in ACLF, terlipressin was associated with better reversal of HRS-AKI and short-term mortality (but more adverse events) than norepi. https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.30208 @hep_journal

Thread over. I look forward to discussing with everyone at #GIJC @GiJournal with great colleagues @elizabeth_verna @salvatore_piano @LizzieAbyMD! Go Dodgers!