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Letter: real‐world use of terlipressin in patients with hepatorenal syndrome

EDITORS, We read with interest the study by Moore et al recently published in Alimentary Pharmacology & Therapeutics regarding the use of terlipressin in patients with cirrhosis and hepatorenal syndrome (HRS) in a realworld setting.1 This multicentre chart review study reported a high response rate of 73% in the studied patients, highest in patients with mild HRS (79.1%) and lowest in those with severe HRS (14.3%). And it was also shown that the shortterm survival correlated with the response to terlipressin. These clinically important findings demonstrated a significant benefit of terlipressin in patients with cirrhosis and HRS in a realworld clinical practice but the following issues need further discussion. First, some relevant information was not reported in the study which prevented a full explanation of the extraordinarily high response rate to terlipressin therapy. It has been proposed that in addition to circulatory dysfunction, systemic inflammation (SI) also plays an important role in the pathogenesis of HRSAKI,2 which cannot be targeted by terlipressin therapy theoretically. Thus, the presence of acuteonchronic liver failure (ACLF), which exhibits more profound systemic inflammation than acute decompensation of cirrhosis, has been associated with higher incidence of HRSAKI and impaired response to terlipressin treatment.3 Therefore, the intensity of SI in patients with HRS may have a significant impact on the response of HRS to therapy. The degree of SI in the studied population could be checked by surrogate markers of SI, such as white blood cell count and C reactive protein, as well as the incidence of ACLF. In addition to the inherent factors associated with disease, there are some unreported confounding factors related to the therapeutic agents used. For example, the duration of terlipressin administration has been found to be significantly longer in patients with improved renal function than in patients without.4 It has also been reported that serum albumin concentration may influence its efficacy in alleviating systemic inflammation and cardiocirculatory dysfunction in patients with decompensated cirrhosis.5 Second, when analysing the correlation between terlipressin response and patient survival, the study did not provide information on liver transplantation, which is an important confounder for survival analysis. As the outcome of liver transplantation is better in patients with AKI that is reversible by pharmacological treatment, liver transplantation would likely be preferred in these patients. Thus, a liver transplantationfree survival and a composite event of liver transplantation and death should preferably be set as the endpoint for analysing the correlation above.