Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury: Frequent Use Beyond Hepatorenal Syndrome

Ann T Ma; Adrià Juanola; Kavish R Patidar; Anna Barone; Simone Incicco; Anand V Kulkarni; Nipun Verma; Christian M Lange; Qing Xie; Carlo Alessandria; Eira Cerda Reyes; Rakhi Maiwall; Jeong Han Kim; Sebastián Marciano; Alberto Queiroz Farias; Claudio Toledo; Silvia Nardelli; Julio D Vorobioff; Juan Pablo Roblero; Thierry Thévenot; Maria Papp; Raoel Maan; Cristina Solé; Jacqueline Cordova-Gallardo; Douglas A Simonetto; Yasser Fouad; Lorenz Balcar; Sarah Raevens; Puria Nabilou; Paolo Caraceni; Manuela Merli; José Presa; Wim Laleman; Aleksander Krag; Tony Bruns; Gustavo Pereira; Angelo Z Mattos; Juan Pablo Arab; Brian Wentworth; Nadia Abdelaaty Abdelkader; Yu Jun Wong; Sung-Eun Kim; Olivier Roux; R Bart Takkenberg; Antonio Galante; Luciana Lofego Goncalves; Nikolaos T Pyrsopoulos; José Luis Pérez Hernández; Sumeet K Asrani; Aldo Torre; International Club of Ascites GLOBAL AKI team

doi:10.1016/j.cgh.2025.08.031

Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury: Frequent Use Beyond Hepatorenal Syndrome

Ann T Ma, Adrià Juanola, Kavish R Patidar, Anna Barone, Simone Incicco, Anand V Kulkarni, Nipun Verma, Christian M Lange, Qing Xie, Carlo Alessandria, Eira Cerda Reyes, Rakhi Maiwall, Jeong Han Kim, Sebastián Marciano, Alberto Queiroz Farias, Claudio Toledo, Silvia Nardelli, Julio D Vorobioff, Juan Pablo Roblero, Thierry ThévenotMaria Papp, Raoel Maan, Cristina Solé, Jacqueline Cordova-Gallardo, Douglas A Simonetto, Yasser Fouad, Lorenz Balcar, Sarah Raevens, Puria Nabilou, Paolo Caraceni, Manuela Merli, José Presa, Wim Laleman, Aleksander Krag, Tony Bruns, Gustavo Pereira, Angelo Z Mattos, Juan Pablo Arab, Brian Wentworth, Nadia Abdelaaty Abdelkader, Yu Jun Wong, Sung-Eun Kim, Olivier Roux, R Bart Takkenberg, Antonio Galante, Luciana Lofego Goncalves, Nikolaos T Pyrsopoulos, José Luis Pérez Hernández, Sumeet K Asrani, Aldo Torre, International Club of Ascites GLOBAL AKI team

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND & AIMS: Terlipressin is indicated to treat hepatorenal syndrome (HRS)-acute kidney injury (AKI) but is likely used outside this primary indication in clinical practice. We aimed to investigate real-world practice patterns on the use of terlipressin in AKI in cirrhosis.

METHODS: International prospective study including patients hospitalized for decompensated cirrhosis. This was a subgroup analysis of patients who received terlipressin to treat AKI. Primary outcome was AKI resolution. Secondary outcomes were respiratory failure and 28-day mortality.

RESULTS: Among 1456 patients with AKI, 243 (17%) received terlipressin. Terlipressin was predominantly administered as a continuous infusion (75%). The AKI phenotype was HRS-AKI in 50%, acute tubular necrosis (ATN) in 17%, hypovolemic in 25%, and other in 8%. AKI resolution occurred in 49% of the patients, and was lowest in ATN (29%), followed by HRS-AKI (51%) and hypovolemic (63%). ATN was independently associated with lack of AKI resolution (odds ratio, 2.77; 95% confidence interval, 1.24-6.54; P = .02). De novo respiratory failure occurred in 20% of patients. There were no significant differences in the amount of albumin received nor acute-on-chronic liver failure grade between those who did and did not develop respiratory failure. The presence of pneumonia independently predicted respiratory failure (odds ratio, 7.80; 95% confidence interval, 2.43-26.95; P < .001). Mortality rate at 28 days was 36%; ATN and hospital-acquired AKI independently predicted 28-day mortality.

CONCLUSIONS: Terlipressin is often used for treatment of AKI outside its primary indication of HRS-AKI. Compared with patients with HRS-AKI, response to terlipressin is significantly lower in patients with ATN, in whom the risks may outweigh the benefits. Respiratory failure is common but does not seem to be driven by the amount of albumin received nor acute-on-chronic liver failure grade.

Original language	English (US)
Journal	Clinical Gastroenterology and Hepatology
DOIs	https://doi.org/10.1016/j.cgh.2025.08.031
State	E-pub ahead of print - Sep 8 2025

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Ma, A. T., Juanola, A., Patidar, K. R., Barone, A., Incicco, S., Kulkarni, A. V., Verma, N., Lange, C. M., Xie, Q., Alessandria, C., Cerda Reyes, E., Maiwall, R., Kim, J. H., Marciano, S., Farias, A. Q., Toledo, C., Nardelli, S., Vorobioff, J. D., Roblero, J. P., ... International Club of Ascites GLOBAL AKI team (2025). Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury: Frequent Use Beyond Hepatorenal Syndrome. Clinical Gastroenterology and Hepatology. Advance online publication. https://doi.org/10.1016/j.cgh.2025.08.031

Ma, AT, Juanola, A, Patidar, KR, Barone, A, Incicco, S, Kulkarni, AV, Verma, N, Lange, CM, Xie, Q, Alessandria, C, Cerda Reyes, E, Maiwall, R, Kim, JH, Marciano, S, Farias, AQ, Toledo, C, Nardelli, S, Vorobioff, JD, Roblero, JP, Thévenot, T, Papp, M, Maan, R, Solé, C, Cordova-Gallardo, J, Simonetto, DA, Fouad, Y, Balcar, L, Raevens, S, Nabilou, P, Caraceni, P, Merli, M, Presa, J, Laleman, W, Krag, A, Bruns, T, Pereira, G, Mattos, AZ, Arab, JP, Wentworth, B, Abdelkader, NA, Wong, YJ, Kim, S-E, Roux, O, Takkenberg, RB, Galante, A, Goncalves, LL, Pyrsopoulos, NT, Pérez Hernández, JL, Asrani, SK, Torre, A & International Club of Ascites GLOBAL AKI team 2025, 'Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury: Frequent Use Beyond Hepatorenal Syndrome', Clinical Gastroenterology and Hepatology. https://doi.org/10.1016/j.cgh.2025.08.031

@article{18b3a1d70e804700bbd5b72c82b76af9,

title = "Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury: Frequent Use Beyond Hepatorenal Syndrome",

abstract = "BACKGROUND \& AIMS: Terlipressin is indicated to treat hepatorenal syndrome (HRS)-acute kidney injury (AKI) but is likely used outside this primary indication in clinical practice. We aimed to investigate real-world practice patterns on the use of terlipressin in AKI in cirrhosis.METHODS: International prospective study including patients hospitalized for decompensated cirrhosis. This was a subgroup analysis of patients who received terlipressin to treat AKI. Primary outcome was AKI resolution. Secondary outcomes were respiratory failure and 28-day mortality.RESULTS: Among 1456 patients with AKI, 243 (17\%) received terlipressin. Terlipressin was predominantly administered as a continuous infusion (75\%). The AKI phenotype was HRS-AKI in 50\%, acute tubular necrosis (ATN) in 17\%, hypovolemic in 25\%, and other in 8\%. AKI resolution occurred in 49\% of the patients, and was lowest in ATN (29\%), followed by HRS-AKI (51\%) and hypovolemic (63\%). ATN was independently associated with lack of AKI resolution (odds ratio, 2.77; 95\% confidence interval, 1.24-6.54; P = .02). De novo respiratory failure occurred in 20\% of patients. There were no significant differences in the amount of albumin received nor acute-on-chronic liver failure grade between those who did and did not develop respiratory failure. The presence of pneumonia independently predicted respiratory failure (odds ratio, 7.80; 95\% confidence interval, 2.43-26.95; P < .001). Mortality rate at 28 days was 36\%; ATN and hospital-acquired AKI independently predicted 28-day mortality.CONCLUSIONS: Terlipressin is often used for treatment of AKI outside its primary indication of HRS-AKI. Compared with patients with HRS-AKI, response to terlipressin is significantly lower in patients with ATN, in whom the risks may outweigh the benefits. Respiratory failure is common but does not seem to be driven by the amount of albumin received nor acute-on-chronic liver failure grade.",

author = "Ma, \{Ann T\} and Adri{\`a} Juanola and Patidar, \{Kavish R\} and Anna Barone and Simone Incicco and Kulkarni, \{Anand V\} and Nipun Verma and Lange, \{Christian M\} and Qing Xie and Carlo Alessandria and \{Cerda Reyes\}, Eira and Rakhi Maiwall and Kim, \{Jeong Han\} and Sebasti{\'a}n Marciano and Farias, \{Alberto Queiroz\} and Claudio Toledo and Silvia Nardelli and Vorobioff, \{Julio D\} and Roblero, \{Juan Pablo\} and Thierry Th{\'e}venot and Maria Papp and Raoel Maan and Cristina Sol{\'e} and Jacqueline Cordova-Gallardo and Simonetto, \{Douglas A\} and Yasser Fouad and Lorenz Balcar and Sarah Raevens and Puria Nabilou and Paolo Caraceni and Manuela Merli and Jos{\'e} Presa and Wim Laleman and Aleksander Krag and Tony Bruns and Gustavo Pereira and Mattos, \{Angelo Z\} and Arab, \{Juan Pablo\} and Brian Wentworth and Abdelkader, \{Nadia Abdelaaty\} and Wong, \{Yu Jun\} and Sung-Eun Kim and Olivier Roux and Takkenberg, \{R Bart\} and Antonio Galante and Goncalves, \{Luciana Lofego\} and Pyrsopoulos, \{Nikolaos T\} and \{P{\'e}rez Hern{\'a}ndez\}, \{Jos{\'e} Luis\} and Asrani, \{Sumeet K\} and Aldo Torre and \{International Club of Ascites GLOBAL AKI team\}",

year = "2025",

month = sep,

day = "8",

doi = "10.1016/j.cgh.2025.08.031",

language = "English (US)",

journal = "Clinical Gastroenterology and Hepatology",

issn = "1542-3565",

publisher = "W.B. Saunders",

}

TY - JOUR

T1 - Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury

T2 - Frequent Use Beyond Hepatorenal Syndrome

AU - Ma, Ann T

AU - Juanola, Adrià

AU - Patidar, Kavish R

AU - Barone, Anna

AU - Incicco, Simone

AU - Kulkarni, Anand V

AU - Verma, Nipun

AU - Lange, Christian M

AU - Xie, Qing

AU - Alessandria, Carlo

AU - Cerda Reyes, Eira

AU - Maiwall, Rakhi

AU - Kim, Jeong Han

AU - Marciano, Sebastián

AU - Farias, Alberto Queiroz

AU - Toledo, Claudio

AU - Nardelli, Silvia

AU - Vorobioff, Julio D

AU - Roblero, Juan Pablo

AU - Thévenot, Thierry

AU - Papp, Maria

AU - Maan, Raoel

AU - Solé, Cristina

AU - Cordova-Gallardo, Jacqueline

AU - Simonetto, Douglas A

AU - Fouad, Yasser

AU - Balcar, Lorenz

AU - Raevens, Sarah

AU - Nabilou, Puria

AU - Caraceni, Paolo

AU - Merli, Manuela

AU - Presa, José

AU - Laleman, Wim

AU - Krag, Aleksander

AU - Bruns, Tony

AU - Pereira, Gustavo

AU - Mattos, Angelo Z

AU - Arab, Juan Pablo

AU - Wentworth, Brian

AU - Abdelkader, Nadia Abdelaaty

AU - Wong, Yu Jun

AU - Kim, Sung-Eun

AU - Roux, Olivier

AU - Takkenberg, R Bart

AU - Galante, Antonio

AU - Goncalves, Luciana Lofego

AU - Pyrsopoulos, Nikolaos T

AU - Pérez Hernández, José Luis

AU - Asrani, Sumeet K

AU - Torre, Aldo

AU - International Club of Ascites GLOBAL AKI team

PY - 2025/9/8

Y1 - 2025/9/8

N2 - BACKGROUND & AIMS: Terlipressin is indicated to treat hepatorenal syndrome (HRS)-acute kidney injury (AKI) but is likely used outside this primary indication in clinical practice. We aimed to investigate real-world practice patterns on the use of terlipressin in AKI in cirrhosis.METHODS: International prospective study including patients hospitalized for decompensated cirrhosis. This was a subgroup analysis of patients who received terlipressin to treat AKI. Primary outcome was AKI resolution. Secondary outcomes were respiratory failure and 28-day mortality.RESULTS: Among 1456 patients with AKI, 243 (17%) received terlipressin. Terlipressin was predominantly administered as a continuous infusion (75%). The AKI phenotype was HRS-AKI in 50%, acute tubular necrosis (ATN) in 17%, hypovolemic in 25%, and other in 8%. AKI resolution occurred in 49% of the patients, and was lowest in ATN (29%), followed by HRS-AKI (51%) and hypovolemic (63%). ATN was independently associated with lack of AKI resolution (odds ratio, 2.77; 95% confidence interval, 1.24-6.54; P = .02). De novo respiratory failure occurred in 20% of patients. There were no significant differences in the amount of albumin received nor acute-on-chronic liver failure grade between those who did and did not develop respiratory failure. The presence of pneumonia independently predicted respiratory failure (odds ratio, 7.80; 95% confidence interval, 2.43-26.95; P < .001). Mortality rate at 28 days was 36%; ATN and hospital-acquired AKI independently predicted 28-day mortality.CONCLUSIONS: Terlipressin is often used for treatment of AKI outside its primary indication of HRS-AKI. Compared with patients with HRS-AKI, response to terlipressin is significantly lower in patients with ATN, in whom the risks may outweigh the benefits. Respiratory failure is common but does not seem to be driven by the amount of albumin received nor acute-on-chronic liver failure grade.

AB - BACKGROUND & AIMS: Terlipressin is indicated to treat hepatorenal syndrome (HRS)-acute kidney injury (AKI) but is likely used outside this primary indication in clinical practice. We aimed to investigate real-world practice patterns on the use of terlipressin in AKI in cirrhosis.METHODS: International prospective study including patients hospitalized for decompensated cirrhosis. This was a subgroup analysis of patients who received terlipressin to treat AKI. Primary outcome was AKI resolution. Secondary outcomes were respiratory failure and 28-day mortality.RESULTS: Among 1456 patients with AKI, 243 (17%) received terlipressin. Terlipressin was predominantly administered as a continuous infusion (75%). The AKI phenotype was HRS-AKI in 50%, acute tubular necrosis (ATN) in 17%, hypovolemic in 25%, and other in 8%. AKI resolution occurred in 49% of the patients, and was lowest in ATN (29%), followed by HRS-AKI (51%) and hypovolemic (63%). ATN was independently associated with lack of AKI resolution (odds ratio, 2.77; 95% confidence interval, 1.24-6.54; P = .02). De novo respiratory failure occurred in 20% of patients. There were no significant differences in the amount of albumin received nor acute-on-chronic liver failure grade between those who did and did not develop respiratory failure. The presence of pneumonia independently predicted respiratory failure (odds ratio, 7.80; 95% confidence interval, 2.43-26.95; P < .001). Mortality rate at 28 days was 36%; ATN and hospital-acquired AKI independently predicted 28-day mortality.CONCLUSIONS: Terlipressin is often used for treatment of AKI outside its primary indication of HRS-AKI. Compared with patients with HRS-AKI, response to terlipressin is significantly lower in patients with ATN, in whom the risks may outweigh the benefits. Respiratory failure is common but does not seem to be driven by the amount of albumin received nor acute-on-chronic liver failure grade.

U2 - 10.1016/j.cgh.2025.08.031

DO - 10.1016/j.cgh.2025.08.031

M3 - Article

C2 - 40930302

SN - 1542-3565

JO - Clinical Gastroenterology and Hepatology

JF - Clinical Gastroenterology and Hepatology

ER -

Real-world Use of Terlipressin in Cirrhosis and Acute Kidney Injury: Frequent Use Beyond Hepatorenal Syndrome

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