Midodrine in the prevention of hepatorenal syndrome type 2 recurrence: A case-control study

Background. Hepatorenal syndrome is a severe complication of cirrhosis. Treatment with terlipressin has currently the best efficacy pedigree, inducing hepatorenal syndrome reversal in a high proportion of patients. However, hepatorenal syndrome recurrence after terlipressin withdrawal is very common, especially in type 2 hepatorenal syndrome. Midodrine, an oral adrenergic vasoconstrictor, has been suggested to be an effective therapy in hepatorenal syndrome. Aims. To analyse the impact of treatment with midodrine after hepatorenal syndrome type 2 reversal induced by terlipressin on the prevention of hepatorenal syndrome recurrence. Patients and methods. A case-control design was Used. The outcome of 10 patients with hepatorenal syndrome type 2 treated successfully with terlipressin and then with midodrine (7.5-12.5 mg/tid) was compared with that of an historical control group of hepatorenal syndrome type 2 patients responders to treatment with terlipressin. Patients and controls were matched by age, plasma renin activity (PRA) levels and severity of renal and liver failure. Results. Cases and controls were similar with respect to pre-treatment with terlipressin. The hepatorenal syndrome recurrence probability was the same in the two groups (cases and control: 9/10, 90%, p = ns). No significant differences were found between cases and controls with respect to serum creatinine (1.9 +/- 0.1 mg/dl vs. 2 +/- 0.2 mg/dl), blood creatinine clearance (28 +/- 5 ml/min vs. 24 +/- 5 ml/min), urinary sodium excretion (12 +/- 6 mequiv./d vs. 19 +/- 4 mequiv./d) and PRA levels (17 +/- 3 ng/ml/h) vs. 20 +/- 3 ng/ml/h) after terlipressin withdrawal (P = ns). Conclusions. These results show that in patients responders to terlipressin hepatorenal syndrome recurrence is not different between patients treated with midodrine and subjects who did not receive vasoconstrictor treatment after terlipressin withdrawal. These data suggest that midodrine is not effective in preventing hepatorenal syndrome type 2 recurrence. (C) 2008 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.