Effect of midodrine on HVPG in advanced chronic liver disease and acute-on-chronic liver failure-A pilot study

Background and Aims Nonselective beta-blockers (NSBB) are the mainstay for treatment of portal hypertension (PH), but require caution in decompensated cirrhosis (DC) or acute-on-chronic liver failure (ACLF) with hypotension, hyponatremia, acute kidney injury (AKI) or type 2 hepatorenal syndrome (HRS). Midodrine is oral, rapidly acting, alpha 1-adrenergic agonist. We evaluated acute effects of midodrine on hepatic venous pressure gradient (HVPG) in DC and ACLF with contraindications to NSBB. Methods Patients of DC (n = 30) with grade III ascites and serum sodium (Na) <130/systolic blood pressure (SBP) <90/type II HRS (group I) and ACLF patients (n = 30) with Na <130/SBP <90/AKI (group II) were included. HVPG was done at baseline and repeated 3 h after 10 mg midodrine. Primary outcome was HVPG response (reduction by >20% or to <12 mmHg). Results In group I, midodrine significantly reduced HVPG (19.2 +/- 4.6 to 17.8 +/- 4.2, p = .02) and heart rate (HR) (86.3 +/- 11.6 to 77.9 +/- 13.1, p < .01) and increased mean arterial pressure (MAP) (74.1 +/- 6.9 to 81.9 +/- 6.6 mmHg, p < .01). In group II also, midodrine reduced HVPG (19.1 +/- 4.1 to 17.0 +/- 4.2) and HR (92.4 +/- 13.7 to 84.6 +/- 14.1) and increased MAP (85.4 +/- 7.3 to 91.2 +/- 7.6 mmHg), p < .01 for all. HVPG response was achieved in 3/30 (10%) in group I and 8/30 (26.7%) in group II. On logistic regression analysis, prerenal AKI (OR 11.04, 95% CI 1.83-66.18, p < .01) and increase in MAP (OR 1.22, 95% CI 1.03-1.43, p = .02) were independent predictors of response. Increase in MAP by 8.5 mmHg with midodrine had best cut-off with AUROC of .76 for response. Conclusion In decompensated cirrhosis and ACLF patients with contraindications to NSBB, midodrine is useful in decreasing HVPG. Dose of midodrine should be titrated to increase MAP atleast by 8.5 mmHg.