A limitation of the trial is that the mortality rate was lower, at 13-19%, compared to previous trials. In response the authors state that mortality rates are similar to trials published in recent years, and that differences in mortality between studies are most likely to reflect variations in patient factors and improvements in general management over the years. These factors include greater number of well-nourished younger patients, improvements in supportive care, lower incidence of infection, acute kidney injury and hepatic encephalopathy. Other factors predicting mortality in this study, Prednisolone use, levels of INR, Bilirubin, Creatinine, Urea, white blood cell count, compared to previous trials were similar. Absence of liver biopsy in this trial may have resulted in inaccurate diagnosis leading to a reduced power of the study to detect a therapeutic effect. The authors state, however, that use of liver biopsy, except when an alternative diagnosis is suspected, is controversial, and is not performed routinely in most units managing patients with AH.
The signs and symptoms of overdosage can be anticipated to include those of excessive pharmacologic effect: dehydration, hypovolemia , hypotension , hyponatremia , hypokalemia , hypochloremic alkalosis , and hemoconcentration. Treatment of overdosage should consist of fluid and electrolyte replacement. Laboratory determinations of serum levels of torsemide and its metabolites are not widely available. No data are available to suggest physiological maneuvers (., maneuvers to change the pH of the urine) that might accelerate elimination of torsemide and its metabolites. Torsemide is not dialyzable, so hemodialysis will not accelerate elimination.