Toe Necrosis after Terlipressin Administration in a Patient with Hepatorenal Syndrome and Pedal Artery Stenosis

A 74-year-old woman with liver cirrhosis presented with hepatorenal syndrome and was treated with terlipressin and albumin. Despite a transient improvement in renal function, the patient developed bilateral toe cyanosis and necrosis during treatment. Computed tomography angiography revealed moderate and severe stenosis of the right and left dorsalis pedis arteries, respectively. Terlipressin was discontinued immediately, and surgical amputation was considered, but deferred because of poor cardiac and hepatic reserves. The patient received conservative wound care but eventually died of multi-organ failure. This case suggests that terlipressin-induced peripheral ischemia can be exacerbated in patients with pre-existing peripheral arterial stenosis or severe cardiac dysfunction. In such high-risk patients, careful evaluation of the vascular and cardiac status before therapy and close monitoring during treatment may help reduce the risk of this rare but serious complication.