OBJECTIVE: 

Hepatorenal syndrome (HRS) is associated with high rates of morbidity and mortality. Evidence examining commonly used drug treatments remains uncertain. We assessed the comparative effectiveness of inpatient treatments for HRS by performing a network meta-analysis of randomized clinical trials (RCTs).

DATA SOURCES: 

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Medline In-Process & Other Non-Indexed Citations, Scopus, and Web of Science from inception.

STUDY SELECTION AND DATA EXTRACTION: 

Pairs of reviewers independently identified eligible RCTs that enrolled patients with type 1 or 2 HRS. Pairs of reviewers independently extracted data.

DATA SYNTHESIS: 

We assessed risk of bias using the Cochrane tool for RCTs and certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach. Our main outcomes are all-cause mortality, HRS reversal, and serious adverse events. Of 3,079 citations, we included 26 RCTs examining 1,736 patients. Based on pooled analysis, terlipressin increases HRS reversal compared with placebo (142 reversals per 1,000 [95% CI, >87.7 to >210.9]; high certainty). Norepinephrine (112.7 reversals per 1,000 [95% CI, 52.6 to >192.3]) may increase HRS reversal compared with placebo (low certainty). The effect of midodrine+octreotide (67.8 reversals per 1,000 [95% CI, <2.8 to >177.4]; very low) on HRS reversal is uncertain. Terlipressin may reduce mortality compared with placebo (93.7 fewer deaths [95% CI, 168.7 to <12.5]; low certainty). Terlipressin probably increases the risk of serious adverse events compared with placebo (20.4 more events per 1,000 [95% CI, <5.1 to >51]; moderate certainty).

CONCLUSIONS: 

Terlipressin increases HRS reversal compared with placebo. Terlipressin may reduce mortality. Until access to terlipressin improves, initial norepinephrine administration may be more appropriate than initial trial with midodrine+octreotide. Our review has the potential to inform future guideline and practice in the treatment of HRS.

中文翻译：

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血管活性治疗肝肾综合征的疗效比较：系统回顾和网络荟萃分析*

客观的： 

肝肾综合征（HRS）与高发病率和死亡率相关。检查常用药物治疗的证据仍不确定。我们通过对随机临床试验 (RCT) 进行网络荟萃分析，评估了 HRS 住院治疗的相对有效性。

数据源： 

我们从一开始就检索了 MEDLINE、Embase、Cochrane Central Register of Controlled Trials、Medline In-Process & Other Non-Indexed Citations、Scopus 和 Web of Science。

研究选择和数据提取： 

成对的评审员独立确定了纳入 1 型或 2 型 HRS 患者的合格随机对照试验。成对的评审员独立提取数据。

数据综合： 

我们使用 Cochrane 随机对照试验工具评估偏倚风险，并使用建议分级、评估、制定和评估方法评估证据的确定性。我们的主要结局是全因死亡率、HRS 逆转和严重不良事件。在 3,079 条引用中，我们纳入了 26 项随机对照试验，检查了 1,736 名患者。根据汇总分析，与安慰剂相比，特利加压素可增加 HRS 逆转（每 1,000 人中有 142 次逆转 [95% CI，>87.7 至 >210.9]；高确定性）。与安慰剂相比，去甲肾上腺素（每 1,000 人中有 112.7 次逆转 [95% CI，52.6 至 >192.3]）可能会增加 HRS 逆转（低确定性）。米多君+奥曲肽（每 1,000 人中有 67.8 次逆转 [95% CI，<2.8 至 >177.4]；非常低）对 HRS 逆转的影响尚不确定。与安慰剂相比，特利加压素可以降低死亡率（死亡人数减少 93.7 人 [95% CI，168.7 至 <12.5]；低确定性）。与安慰剂相比，特利加压素可能会增加严重不良事件的风险（每 1,000 人中发生的事件增加 20.4 次 [95% CI，<5.1 至 >51]；中等确定性）。

结论： 

与安慰剂相比，特利加压素可增加 HRS 逆转。特利加压素可以降低死亡率。在特利加压素的使用得到改善之前，最初的去甲肾上腺素给药可能比最初的米多君+奥曲肽试验更合适。我们的综述有可能为未来 HRS 治疗的指南和实践提供信息。