Use of terlipressin in critically ill children with liver disease
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RESEARCH ARTICLE
Open Access
Use of terlipressin in critically ill children with liver disease Romit Saxena, Aravind Anand and Akash Deep*
Abstract Background: Terlipressin, a long-acting synthetic analogue of vasopressin has been used in the adult population for various indications including hepatorenal syndrome (HRS-AKI), esophageal variceal hemorrhage (EVH) and shock, but its use in pediatrics is still limited to individualized cases and data on safety and efficacy is scant. Methods: We reviewed the patient records of children with liver disease and Acute Kidney Injury requiring terlipressin admitted to the Paediatric Intensive Care Unit (PICU) of King’s College Hospital, London from January 2010–December 2017, with special emphasis on its effect on renal parameters and adverse event profile. Results: Twenty-one terlipressin administration records in a total of 16 patients (median) (IQR) 10 years (6.1–14.4) were included. The drug was initially given as a bolus dose in all cases, followed by either bolus or infusion with median dosage being 5.2 (3.8–6.7) mcg/kg/hour. After administration, a sustained increase of mean arterial pressure was observed. There was an improvement in serum creatinine (Cr) (at 24 h; p = 0.386) and increase in urine output (UO), especially in the hepatorenal syndrome subgroup (HRS-AKI). We found minimal evidence of gastrointestinal side effects including feeding intolerance and vasoconstrictive side effects including cyanosis / ischaemia of extremities. Conclusion: Terlipressin was found to be safe in critically sick children with liver disease with positive impact on renal parameters which might be taken as a surrogate marker of HRS reversal, though effects on outcomes are difficult to ascertain. It is important to be aware of all its side-effects and actively watch for them. Future prospective studies are warranted to validate these findings. Keywords: Hepatorenal syndrome, Pediatrics, Liver disease, Acute kidney injury, Terlipressin
Background Terlipressin (triglycyl lysine vasopressin), is a long-acting synthetic analogue of vasopressin. The distribution halflife of terlipressin is 8 min and it gets eliminated in 50 min [1, 2]. Vasopressin and its analogues have been used for indications such as septic shock (especially catecholamine refractory septic shock) [3–6], bleeding esophageal varices [7–9] and hepatorenal syndrome (HRS-AKI) [10, 11]. But, its use and research has been limited predominantly to the adult population. Unique pathophysiology of HRS
(splanchnic vasodilatation) justifies the use of a splanchnic vasoconstrictor like terlipressin. Use of terlipressin in children has been limited to vasodilatory shock [12, 13]. Experience in pediatric population, for indications as hepatorenal syndrome, has been limited to small case series [14]. We retrospectively analyzed case records of children with liver disease treated with terlipressin in our tertiary PICU (Paediatric intensive care unit) in London. The aim of this retrospective study was to analyze changes in hemodynamic,
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