Abstract

Significance: Hepatorenal syndrome (HRS) is a multiorgan condition of acute kidney injury (AKI) in the setting of advanced liver disease. Albumin therapy can help reduce splanchnic vasodilation, suppress renin-angiotensin-aldosterone system, and reduce renal vasoconstriction, potentially improving renal perfusion and resolving HRS. Midodrine and octreotide can be added to albumin therapy to improve renal function and short-term survival. Terlipressin, a synthetic vasopressin analogue that reduces portal pressure and increases arterial blood volume and renal blood flow, has been widely available outside of the United States for HRS management.  A randomized controlled trial was recently published comparing terlipressin versus placebo (CONFIRM trial) in patients with HRS–AKI and showed terlipressin, in combination with albumin, is associated with higher likelihood of HRS reversal and 10–day survival without renal replacement therapy compared to placebo. Trial results facilitated Federal Drug Administration approval of terlipressin in the United States.

Purpose: To assess the appropriate use of albumin, midodrine, and octreotide and the outcomes of the treatments provided. Utilize the data to guide the possible addition of terlipressin to formulary at these two institutions

Methods: This retrospective review of suspected and confirmed HRS patients from January 2023 through August 2025 at two large academic teaching hospitals. Data was collected for adult patients above 18 years of age with documentation of HRS who received albumin 25% alone, albumin 25% +/- midodrine, +/- octreotide. The primary endpoint was to evaluate the appropriate use of albumin, midodrine, and octreotide for the management of HRS and subsequent rates of reversal between treatment groups.

Results: A total of 46% of patients achieved hepatorenal reversal and 34% received optimal therapy. Intensive care unit (ICU) admission occurred in 32% of patients and median ICU length of stay was 2 days. Renal replacement therapy was required in 21% of patients and 9% required TIPS. Hospital mortality or transition to hospice care occurred in 59% of patients.

Discussion: Implementation of a standardize HRS treatment protocol may optimize therapy and reduce hospital length of stay and ICU admission, as HRS is associated with significant healthcare burden including a 9-day median length of stay, ICU admissions, and renal replacement therapy. 50% of patients met the proposed criteria for terlipressin use, supporting further evaluation for formulary consideration. Limitations included small sample size, lack of standardized protocol, variability in practice, mortality confounded by terminal disease states, retrospective evaluation of terlipressin candidates with proposed use criteria, and inability to extrapolate outcomes in potential terlipressin candidates.

Publication Date

Winter 12-10-2025

Presented At:

Midyear Clinical Meeting and Exhibition (ASHP)

Content Type

Poster

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