Terlipressin

Terlipressin, marketed as Terlivaz, is converted gradually into lysine-vasopressin, giving a more prolonged effect than vasopressin itself. It treats hepatorenal syndrome in advanced liver disease, a form of acute renal failure with poor prognosis. It was used internationally before US approval in 2022.

After enzymatic cleavage, active lysine-vasopressin acts mainly at V1a receptors. In hepatorenal syndrome, excessive splanchnic arterial dilation reduces effective circulating volume and renal perfusion. Constriction of those gut vessels reduces pooling and redistributes blood toward systemic/kidney circulation.

The aim is renal reversal while liver disease is addressed, sometimes as a bridge to transplantation. CONFIRM reported hepatorenal-syndrome reversal in about 32% on terlipressin versus 17% with placebo, but respiratory complications were more frequent on active treatment.

Terlivaz received FDA approval in 2022 to improve kidney function in adults with hepatorenal syndrome and rapidly deteriorating renal function. It is administered IV in hospital with careful oxygenation monitoring. A boxed warning covers serious or fatal respiratory failure; use is avoided in hypoxic patients and those with high baseline respiratory/ischemic risk.

Abdominal pain, nausea, diarrhea and shortness of breath are common effects. Fluid overload increases respiratory-failure risk. Vasoconstriction can cause ischemia in the heart, brain, gut, digits or skin. Respiratory failure or ischemia may jeopardize eligibility for liver transplantation, making patient selection and ongoing monitoring essential.