The management of hepatorenal syndrome–acute kidney injury (HRS-AKI): A national survey of hepatology provider practices
Year: 2026
Type: article
Study design: Observational Study
Abstract: BACKGROUND: Hepatorenal syndrome-acute kidney injury (HRS-AKI) is associated with high mortality in cirrhosis. Recent FDA approval of terlipressin and updated clinical guidance have expanded management options, but real-world practice patterns remain unknown. METHODS: We conducted a nationwide survey of U.S. hepatology providers regarding HRS-AKI management practices. The 33-question survey assessed provider demographics, vasoconstrictor selection, treatment timing, and adherence to guideline recommendations. RESULTS: Among 162 respondents, most were hepatologists (94%) at academic centers (83%). Only 11% obtained a nephrology consultation at AKI detection, with 44% waiting until worsening renal function. Terlipressin was available at 80% of institutions but more commonly at academic centers (84% vs. 53%, p=0.003). Consistent with guideline recommendations, 77% of providers initiate vasoconstrictors only after completing a trial of volume expansion (if no renal improvement), particularly in academic centers (80% vs. 60% non-academic, p=0.03). Terlipressin (49%) and midodrine/octreotide (44%) were preferred first-line treatments, with providers at academic centers more likely to use midodrine/octreotide (46% vs. 30%, p=0.008). Mean arterial pressure was used by 62% of providers to guide vasoconstrictor dosing. Most providers (73%) discontinued vasoconstrictor treatment after 4 days if no improvement. CONCLUSIONS: Significant variations exist between guideline recommendations and real-world HRS-AKI management, especially first-line treatment choice, treatment monitoring, and nephrology consultation. These findings highlight opportunities to improve guideline implementation and identify areas where practice patterns might inform provider education and future guidance updates.
Source: Hepatology Communications
Authors: Giuseppe Cullaro, Gene Y. Im, Shaun Chandna, Brian T. Lee, Douglas A. Simonetto, Elizabeth S. Aby, Manhal Izzy, Stevan A. Gonzalez, Courtney B. Sherman, Joshua Aron, Jay Luther, Aparna Goel, Loretta L. Jophlin, John Rice, Po-Hung Chen, Sumeet Asrani, Blanca Lizaola-Mayo, Mohamed Elfeki, Florence Wong, Scott W. Biggins, Guadalupe Garcia-Tsao, Ashwani K. Singal
Institutions: Columbia University, University of California, Los Angeles, Olive View-UCLA Medical Center, Hoag Memorial Hospital Presbyterian, Mayo Clinic, University of Minnesota, Vanderbilt University, Vanderbilt University Medical Center, Texas Christian University, Baylor Scott & White All Saints Medical Center, University of California, San Francisco, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Massachusetts General Hospital, Stanford Medicine, Stanford University, University of Louisville, University of Wisconsin–Madison, Johns Hopkins University, Johns Hopkins Medicine, Baylor University Medical Center, Baylor Scott & White Health, Mayo Clinic in Arizona, University of South Dakota, University of Toronto, University of Pittsburgh, Yale University, VA Connecticut Healthcare System
Language: English
Subfield: Hepatology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,700
Funder: National Institutes of Health
OpenAlex ID: W7146947553