Abstract

Purpose/Background: Hepatorenal syndrome (HRS) is a severe complication of advanced liver disease characterized by acute kidney injury (AKI) and high mortality rates exceeding 50%. Standard management includes albumin with vasoconstrictors such as midodrine and octreotide. Terlipressin was approved by the Food and Drug Administration in 2022 for HRS based on clinical trials demonstrating higher rates of HRS reversal. Norepinephrine has shown comparable efficacy to terlipressin in achieving HRS reversal in several studies, particularly in intensive care unit (ICU) settings, offering an effective and more accessible alternative. Despite the updated evidence available, real-world utilization and outcomes of these therapies remain variable. This study aimed to evaluate current prescribing trends and clinical outcomes of HRS management across a multi-site health system and assess projected utilization of terlipressin.

Methods: This multi-center, retrospective chart review included adult patients treated for HRS at Baptist Health South Florida between January 2023 and August 2025. Patients who received albumin 25% alone or in combination with midodrine and/or octreotide and vasopressors were included. The primary outcome was HRS reversal, defined as reduction in serum creatinine (SCr) to ≤1.5 mg/dL or within 0.3 mg/dL of baseline, or if SCr did not meet criteria for reversal but the patient was clinically stable for discharge. Secondary outcomes included ICU and hospital length of stay, need for renal replacement therapy (RRT), patient disposition, and eligibility for terlipressin based upon our institutions approved criteria for use. Descriptive statistics were used for analysis.

Results: A total of 100 patients were screened, with 76 patients included in the final analysis. Twenty-four patients were excluded due to transfer to another institution or stratification to hospice care. Baseline characteristics demonstrated a median age of 62 years with 67% male patients. The majority had HRS-AKI (72%), and common etiologies of cirrhosis included alcohol-related liver disease (53%) and malignancy (26%). Median baseline SCr was 2.5 mg/dL. Overall, 65% of patients achieved HRS reversal or stability. Patients managed on the floor demonstrated a 95% reversal rate compared to 29% in the ICU. The highest reversal rates were observed with combination therapy. Mean ICU length of stay was 2.8 days, and 26% of patients required RRT. Mortality was 29%, consistent with expected outcomes in this population. Only 25% of patients met institutional criteria for terlipressin use.

Conclusion: HRS management at our institution resulted in high rates of reversal or stability, particularly among patients treated on the floor without escalation of care. These findings suggest that effective early management with albumin-based regimens may reduce the need for ICU admission and limit the clinical necessity for terlipressin in a majority of patients. Limited candidacy and favorable outcomes without terlipressin should be considered when evaluating formulary adoption.

Publication Date

Spring 5-15-2026

Presented At:

Florida Residency Conference

Content Type

Presentation

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