Terlipressin Infusion Dosing for Hepatorenal Syndrome-Acute Kidney Injury
Terlipressin can be administered as a continuous intravenous infusion at a starting dose of 2 mg/day, which may be gradually increased every 24-48 hours up to a maximum dose of 12 mg/day, or until reversal of HRS-AKI is achieved. 1, 2
Administration Options
Continuous Infusion Method (Preferred)
- Starting dose: 2 mg/day as continuous IV infusion
- Dose titration: Increase gradually every 24-48 hours if no reduction in serum creatinine by at least 25% from baseline
- Maximum dose: 12 mg/day
- Advantages: Lower incidence of ischemic side effects, more stable effect on portal pressure 1, 3
Bolus Administration Method (Alternative)
- Starting dose: 1 mg IV every 4-6 hours (total 4-6 mg/day)
- Dose titration: Increase to 2 mg every 4-6 hours (total 8-12 mg/day) if no reduction in serum creatinine by at least 25% from baseline by day 3
- Maximum dose: 12 mg/day (2 mg every 4-6 hours) 1, 2
Concurrent Albumin Administration
Treatment Duration
- Continue until serum creatinine returns to within ≤0.3 mg/dL of baseline for 2 consecutive days
- Maximum treatment duration: 14 days 1, 2
Monitoring Requirements
- Renal function: Monitor serum creatinine regularly to assess response
- Vital signs: Monitor blood pressure, heart rate, and urine output
- Respiratory status: Continuous pulse oximetry recommended; discontinue if SpO₂ <90%
- Ischemic complications: Monitor for signs of digital, cardiac, or intestinal ischemia 2
Contraindications
- Serum creatinine ≥5 mg/dL
- Oxygen saturation <90%
- Ongoing coronary, peripheral, or mesenteric ischemia 1, 2
Efficacy and Safety Considerations
- Continuous infusion has been shown to be equally effective at lower doses compared to bolus administration, with fewer adverse events 3, 4
- Recent evidence suggests that continuous infusion at 4 mg/day may be well-tolerated with similar outcomes to 2 mg/day, potentially requiring less albumin 4
- The most common adverse events include:
Clinical Pearls
- Perform ECG screening before initiating treatment
- Use with caution in patients with acute-on-chronic liver failure grade 3 and high MELD scores (≥35)
- Consider discontinuing treatment if serum creatinine is at or above baseline value on day 4
- Terlipressin plus albumin is more effective than albumin alone in improving renal function in HRS-AKI 2, 6, 5
Continuous infusion appears to be the preferred administration method due to more stable hemodynamic effects and fewer adverse events compared to bolus dosing, while maintaining similar efficacy in the treatment of HRS-AKI.