Recommendations on the Diagnosis and Initial Management of Acute Variceal Bleeding and Hepatorenal Syndrome in Patients with Cirrhosis

  • Frederik NevensEmail author
  • Paulo Lisboa Bittencourt
  • Minneke J. Coenraad
  • Huiguo Ding
  • Ming-Chih Hou
  • Pierre-François Laterre
  • Manuel Mendizabal
  • Nayeli Xochiquetzal Ortiz-Olvera
  • Julio D. Vorobioff
  • Wenhong Zhang
  • Paolo Angeli


Cirrhosis is a serious and life-threatening condition which imposes a significant socioeconomic burden on affected individuals and healthcare systems. Cirrhosis can result in portal hypertension, which may lead to major complications, including acute variceal bleeding and hepatorenal syndrome. Without prompt treatment, these complications may be life-threatening. Over the past 2 decades, new treatment modalities and treatment strategies have been introduced, which have improved patients’ prognosis, but the initial management of these severe complications continues to present a challenge. The present recommendations aim to increase clinicians’ knowledge on the importance of early diagnosis and treatment, and to provide evidence-based management strategies to potentially, further improve patient outcomes. Special attention was given to the role of terlipressin. A comprehensive non-systematic literature search was undertaken to evaluate the evidence for the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis. Recommendations on the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis have been developed based on the best available evidence and the expert opinion of the consensus panel following a comprehensive review of the available clinical data. Prompt identification and timely treatment of acute variceal bleeding and hepatorenal syndrome are essential to reduce the burden.


Acute variceal bleeding Acute kidney injury Hepatorenal syndrome Cirrhosis Terlipressin Vasoactive drugs 



In China, this study was supported by the State Key Projects Specialized on Infectious Diseases (2017ZX10203202-004) and Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding (ZYLX201610) for Dr Huiguo Ding.


The study was sponsored by Ferring Pharmaceuticals. The manuscript was written by Strategen Ltd, who received funding from Ferring Pharmaceuticals in this regard. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole and have given final approval to the version to be published. Ferring Pharmaceuticals reviewed the manuscript but editorial control rested solely with the authors.

Compliance with ethical standards

Conflicts of interest

Frederik Nevens has received a consultancy grant from Ferring. Manuel Mendizabal has received payments for lectures from Bristol-Myers Squibb, AbbVie, Gilead, Ferring and Bayer; honoraria for consulting from Ferring and Gilead. Paolo Angeli declares the following: 2014–2018: Sequana Medical AG Advisory Board; 2016–2018: Biovie Advisory Board and patent application; 2016 Gilead (Italy): Advisory board and grant; 2014 Bhering: travel grant; 2016 Kedrion: speaker invitation. Paulo Lisboa Bittencourt, Minneke J Coenraad, Huiguo Ding, Ming-Chih Hou, Pierre-François Laterre, Nayeli Xochiquetzal Ortiz-Olvera, Julio D. Vorobioff, Wenhong Zhang declare that they have no conflict of interest.


  1. 1.
    Scalone L, Fagiuoli S, Ciampichini R, et al. The societal burden of chronic liver diseases: results from the COME study. BMJ Open Gastroenterol. 2015;2:e000025.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Neff GW, Duncan CW, Schiff ER. The current economic burden of cirrhosis. Gastroenterol Hepatol (N Y). 2011;7:661–671.Google Scholar
  3. 3.
    Scaglione S, Kliethermes S, Cao G, et al. The epidemiology of cirrhosis in the United States: a population-based study. J Clin Gastroenterol. 2015;49:690–696.PubMedCrossRefGoogle Scholar
  4. 4.
    GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–171.CrossRefGoogle Scholar
  5. 5.
    Zatoński WA, Sulkowska U, Mańczuk M, et al. Liver cirrhosis mortality in Europe, with special attention to Central and Eastern Europe. Eur Addict Res. 2010;16:193–201.PubMedCrossRefGoogle Scholar
  6. 6.
    LaBrecque D, Khan AG, Sarin SK, LeMair AW. Esophageal Varices. World Gastroenterology Organisation Global Guidelines; 2014.Google Scholar
  7. 7.
    Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol. 2013;19:5035–5050.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Triantafyllou M, Stanley AJ. Update on gastric varices. World J Gastrointest Endosc. 2014;6:168–175.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Wani ZA, Bhat RA, Bhadoria AS, Maiwall R, Choudhury A. Gastric varices: classification, endoscopic and ultrasonographic management. J Res Med Sci. 2015;20:1200–1207.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80:800–899.PubMedGoogle Scholar
  11. 11.
    Nevens F. Novel approaches to reducing the risk of variceal hemorrhage. Dig Dis. 2017;35:397–401.PubMedCrossRefGoogle Scholar
  12. 12.
    de Franchis. On behalf of the Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–752.PubMedCrossRefGoogle Scholar
  13. 13.
    Garcia-Pagán JC, Caca K, Bureau C, et al. Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) cooperative study group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;24:2370–2379.CrossRefGoogle Scholar
  14. 14.
    Jairath V, Rehal S, Logan R, et al. Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit. Dig Liver Dis. 2014;46:419–426.PubMedCrossRefGoogle Scholar
  15. 15.
    Bucsics T, Krones E. Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome. Gastroenterol Rep. 2017;5:127–137.CrossRefGoogle Scholar
  16. 16.
    Salerno F, Cazzaniga M, Merli M, et al. Diagnosis, treatment and survival of patients with hepatorenal syndrome: a survey on daily medical practice. J Hepatol. 2011;55:1241–1248.PubMedCrossRefGoogle Scholar
  17. 17.
    Salerno F, Gerbes A, Ginès P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56:1310–1318.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Wadei HM, Mai ML, Ashan N, Gonwa TA. Hepatorenal syndrome: pathophysiology and management. Clin J Am Soc Nephrol. 2006;1:1066–1079.PubMedCrossRefGoogle Scholar
  19. 19.
    Ginès A, Escorsell A, Ginès P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993;105:229–236.PubMedCrossRefGoogle Scholar
  20. 20.
    Gifford FJ, Morling JR, Fallowfield JA. Systematic review with meta-analysis: vasoactive drugs for the treatment of hepatorenal syndrome type 1. Aliment Pharmacol Ther. 2017;45:593–603.PubMedCrossRefGoogle Scholar
  21. 21.
    Howick J, Chalmers I, Glasziou P, et al. The 2011 Oxford Centre for Evidence-Based Medicine Levels of Evidence: Introductory Document. Oxford Centre for Evidence-Based Medicine. Available at: Accessed August 22, 2018.
  22. 22.
    OCEBM Levels of Evidence Working Group. Oxford Centre for Evidence-Based Medicine—Levels of Evidence (March 2009). Available at: Accessed August 22, 2018.
  23. 23.
    Tripathi D, Stanley AJ, Hayes PC, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64:1680–1704.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65:310–335.PubMedCrossRefGoogle Scholar
  25. 25.
    Bernard B, Grangé JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999;29:1655–1661.PubMedCrossRefGoogle Scholar
  26. 26.
    Bañares R, Albillos A, Rincón D, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology. 2002;35:609–615.PubMedCrossRefGoogle Scholar
  27. 27.
    Wells M, Chande N, Adams P, Beaton M, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012;35:1267–1278.PubMedCrossRefGoogle Scholar
  28. 28.
    Söderlund C, Magnusson I, Törngren S, Lundell L. Terlipressin (triglycyl-lysine vasopressin) controls acute bleeding oesophageal varices. A double-blind, randomized, placebo-controlled trial. Scand J Gastroenterol. 1990;25:622–630.PubMedCrossRefGoogle Scholar
  29. 29.
    Freeman JG, Cobden I, Record CO. Placebo-controlled trial of terlipressin (glypressin) in the management of acute variceal bleeding. J Clin Gastroenterol. 1989;11:58–60.PubMedCrossRefGoogle Scholar
  30. 30.
    Walker S, Stiehl A, Raedsch R, Kommerell B. Terlipressin in bleeding esophageal varices: a placebo-controlled, double-blind study. Hepatology. 1986;6:112–115.PubMedCrossRefGoogle Scholar
  31. 31.
    Levacher S, Letoumelin P, Pateron D, Blaise M, Lapandry C, Pourriat JL. Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients. Lancet. 1995;346:865–868.PubMedCrossRefGoogle Scholar
  32. 32.
    Ioannou GN, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev. 2003; Art. No: CD002147.Google Scholar
  33. 33.
    Seo YS, Park SY, Kim JH, et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology. 2014;60:954–963.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Abid S, Jafri W, Hamid S, et al. Terlipressin versus octreotide in bleeding esophageal varices as an adjuvant therapy with endoscopic band ligation: a randomized double-blind placebo-controlled trial. Am J Gastroenterol. 2009;104:617–623.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Feu F, RuizdelArbol L, Bañares R, Planas R, Bosch J. Double-blind randomized controlled trial comparing terlipressin and somatostatin for acute variceal hemorrhage. Variceal Bleeding Study Group. Gastroenterology. 1996;111:1291–1299.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Walker S, Kreichgauer HP, Bode JC. Terlipressin (glypressin) versus somatostatin in the treatment of bleeding esophageal varices—final report of a placebo-controlled, double-blind study. Z Gastroenterol. 1996;34:692–698.PubMedGoogle Scholar
  37. 37.
    Pedretti G, Elia G, Calzetti C, Magnani G, Fiaccadori F. Octreotide versus terlypressin in acute variceal hemorrhage in liver cirrhosis. Emergency control and prevention of early rebleeding. Clin Investig. 1994;72:653–659.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Silvain C, Carpentier S, Sautereau D, et al. Terlipressin plus transdermal nitroglycerin vs. octreotide in the control of acute bleeding from esophageal varices: a multicenter randomized trial. Hepatology. 1993;18:61–65.PubMedGoogle Scholar
  39. 39.
    Bittencourt PL, Farias AQ, Strauss E, et al. Pannel of the 1st Brazilian Consensus of Variceal Bleeding, Brazilian Society of Hepatology. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. Arq Gastroenterol. 2010;47:202–216.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Krag A, Borup T, Møller S, et al. Efficacy and safety of terlipressin in cirrhotic patients with variceal bleeding or hepatorenal syndrome. Adv Ther. 2008;25:1105–1140.PubMedCrossRefGoogle Scholar
  41. 41.
    Sola E, Lens S, Guevara M, et al. Hyponatremia in patients treated with terlipressin for severe gastrointestinal bleeding due to portal hypertension. Hepatology. 2010;52:1783–1790.PubMedCrossRefGoogle Scholar
  42. 42.
    Yim SY, Seo YS, Jung CH, et al. Risk factors for developing hyponatremia during terlipressin treatment: a retrospective analyses in variceal bleeding. J Clin Gastroenterol. 2015;49:607–612.PubMedCrossRefGoogle Scholar
  43. 43.
    Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol. 2014;60:643–653.PubMedCrossRefGoogle Scholar
  44. 44.
    Kalambokis G, Economou M, Paraskevi K, et al. Effects of somatostatin, terlipressin and somatostatin plus terlipressin on portal and systemic hemodynamics and renal sodium excretion in patients with cirrhosis. J Gastroenterol Hepatol. 2005;20:1075–1081.PubMedCrossRefGoogle Scholar
  45. 45.
    Lin HC, Yang YY, Hou MC, et al. Hemodynamic effects of a combination of octreotide and terlipressin in patients with viral hepatitis related cirrhosis. Scand J Gastroenterol. 2002;37:482–487.PubMedCrossRefGoogle Scholar
  46. 46.
    Nidegger D, Ragot S, Berthelémy P, et al. Cirrhosis and bleeding: the need for very early management. J Hepatol. 2003;39:509–514.PubMedCrossRefGoogle Scholar
  47. 47.
    Avgerinos A, Nevens F, Raptis S, Fevery J. Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABEVE) randomised trial. Lancet. 1997;350:1495–1499.PubMedCrossRefGoogle Scholar
  48. 48.
    Calès P, Masliah C, Bernard B, et al. Early administration of vapreotide for variceal bleeding in patients with cirrhosis. French Club for the Study of Portal Hypertension. N Engl J Med. 2001;344:23–28.PubMedCrossRefGoogle Scholar
  49. 49.
    Escorsell A, Bandi JC, Moitinho E, et al. Time profile of the haemodynamic effects of terlipressin in portal hypertension. J Hepatol. 1997;26:621–627.PubMedCrossRefGoogle Scholar
  50. 50. Identifier: NCT0269586, To assess safety and efficacy of bolus versus continuous infusion of terlipressin in acute variceal bleeding. Available at:
  51. 51.
    Chang TT, Lee FY, Tsai YT, et al. A randomized controlled study of low-dose and high-dose terlipressin in the control of acute oesophageal variceal haemorrhage. J Gastroenterol Hepatol. 1991;6:481–484.PubMedCrossRefGoogle Scholar
  52. 52.
    Azam Z, Hamid S, Jafri W, et al. Short course adjuvant terlipressin in acute variceal bleeding: a randomized double blind dummy controlled trial. J Hepatol. 2012;56:819–824.PubMedCrossRefGoogle Scholar
  53. 53.
    Garcia-Pagán JC, Di Pascoli M, Caca K, et al. Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol. 2013;58:45–50.PubMedCrossRefGoogle Scholar
  54. 54.
    Altraif I, Handoo FA, Aljumah A, et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointest Endosc. 2011;73:245–250.PubMedCrossRefGoogle Scholar
  55. 55.
    Brunner F, Berzigotti A, Bosch J. Prevention and treatment of variceal haemorrhage in 2017. Liver Int. 2017;37:104–115.PubMedCrossRefGoogle Scholar
  56. 56.
    Cipolletta L, Zambelli A, Bianco MA, et al. Acrylate glue injection for acutely bleeding oesophageal varices: a prospective cohort study. Dig Liver Dis. 2009;41:729–734.PubMedCrossRefGoogle Scholar
  57. 57.
    Ribeiro JP, Matuguma SE, Cheng S, et al. Results of treatment of esophageal variceal hemorrhage with endoscopic injection of n-butyl-2-cyanoacrylate in patients with Child-Pugh class C cirrhosis. Endosc Int Open. 2015;3:584–589.CrossRefGoogle Scholar
  58. 58.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–938.PubMedCrossRefGoogle Scholar
  59. 59.
    Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol. 2002;97:1010–1015.PubMedCrossRefGoogle Scholar
  60. 60.
    Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001;33:1060–1064.PubMedCrossRefGoogle Scholar
  61. 61.
    Huang YH, Yeh HZ, Chen GH, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc. 2000;52:160–167.PubMedCrossRefGoogle Scholar
  62. 62.
    Lee YT, Chan FK, Ng EK, et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc. 2000;52:168–174.PubMedCrossRefGoogle Scholar
  63. 63.
    Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R. Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population. Can J Gastroenterol. 2010;24:593–596.PubMedPubMedCentralCrossRefGoogle Scholar
  64. 64.
    Ríos Castellanos E, Seron P, Gisbert JP, Bonfill Cosp X. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev. 2015; Art. No.: CD010180.Google Scholar
  65. 65.
    Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology. 1998;114:981–987.PubMedCrossRefGoogle Scholar
  66. 66.
    Azoulay D, Castaing D, Majno P, et al. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol. 2001;35:590–597.PubMedCrossRefGoogle Scholar
  67. 67.
    Lo GH, Liang HL, Chen WC, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007;39:679–685.PubMedCrossRefGoogle Scholar
  68. 68.
    Arroyo V, Ginès P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996;23:164–176.PubMedCrossRefGoogle Scholar
  69. 69.
    Angeli P, Ginès P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol. 2015;62:968–974.PubMedCrossRefGoogle Scholar
  70. 70.
    Rodriguez E, Elia C, Solà E, et al. Terlipressin and albumin for type-1 hepatorenal syndrome associated with sepsis. J Hepatol. 2014;60:955–961.PubMedCrossRefGoogle Scholar
  71. 71.
    Boyer TD, Sanyal AJ, Garcia-Tsao G, et al. Predictors of response to terlipressin plus albumin in hepatorenal syndrome (HRS) type 1: relationship of serum creatinine to hemodynamics. J Hepatol. 2011;55:315–321.PubMedCrossRefGoogle Scholar
  72. 72.
    European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53:397–417.CrossRefGoogle Scholar
  73. 73.
    Garcovich M, Zocco MA, Gasbarrini A. Clinical use of albumin in hepatology. Blood Transfus. 2009;7:268–277.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Dobre M, Demirjian S, Sehgal AR, Navaneethan SD. Terlipressin in hepatorenal syndrome: a systematic review and meta-analysis. Int Urol Nephrol. 2011;43:175–184.PubMedCrossRefGoogle Scholar
  75. 75.
    Fabrizi F, Dixit V, Messa P, Martin P. Terlipressin for hepatorenal syndrome: a meta-analysis of randomized trials. Int J Artif Organs. 2009;32:133–140.PubMedCrossRefGoogle Scholar
  76. 76.
    Boyer TD, Sanyal AJ, Wong F, et al. For REVERSE Study Investigators. Terlipressin plus albumin is more effective than albumin alone in improving renal function in patients with cirrhosis and hepatorenal syndrome type 1. Gastroenterology. 2016;150:1579–1589.e2.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Sanyal AJ, Boyer TD, Frederick RT, et al. Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin versus placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studies. Aliment Pharmacol Ther. 2017;45:1390–1402.PubMedPubMedCentralCrossRefGoogle Scholar
  78. 78.
    Gluud LL, Christensen K, Christensen E, Krag A. Terlipressin for hepatorenal syndrome. Cochrane Database Syst Rev. 2012;9:CD005162.Google Scholar
  79. 79.
    Martín-Llahí M, Pepin MN, Guevara M, et al. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology. 2008;134:1352–1359.PubMedCrossRefGoogle Scholar
  80. 80.
    Neri S, Pulvirenti D, Malaguarnera M, et al. Terlipressin and albumin in patients with cirrhosis and type I hepatorenal syndrome. Dig Dis Sci. 2008;53:830–835. Scholar
  81. 81.
    Goyal O, Sidhu SS, Sehgal N, Puri S. Noradrenaline is as effective as terlipressin in hepatorenal syndrome type 1: a prospective, randomized trial. J Assoc Phys India. 2016;64:30–35.Google Scholar
  82. 82.
    Singh V, Ghosh S, Singh B, et al. Noradrenaline vs. terlipressin in the treatment of hepatorenal syndrome: a randomized study. J Hepatol. 2012;56:1293–1298.PubMedCrossRefGoogle Scholar
  83. 83.
    Sharma P, Kumar A, Shrama BC, Sarin SK. An open label, pilot, randomized controlled trial of noradrenaline versus terlipressin in the treatment of type 1 hepatorenal syndrome and predictors of response. Am J Gastroenterol. 2008;103:1689–1697.PubMedCrossRefGoogle Scholar
  84. 84.
    Alessandria C, Ottobrelli A, Debernardi-Venon W, et al. Noradrenalin versus terlipressin in patients with hepatorenal syndrome: a prospective, randomized, unblinded, pilot study. J Hepatol. 2007;47:499–505.PubMedCrossRefGoogle Scholar
  85. 85.
    Cavallin M, Kamath PS. Italian Association for the Study of the Liver Study Group on Hepatorenal Syndrome. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: a randomized trial. Hepatology. 2015;62:567–574.PubMedCrossRefGoogle Scholar
  86. 86.
    Cavallin M, Piano S, Romano A, et al. Terlipressin given by continuous intravenous infusion versus intravenous boluses in the treatment of hepatorenal syndrome: a randomized controlled study. Hepatology. 2016;63:983–992.PubMedCrossRefGoogle Scholar
  87. 87.
    Arroyo V, Moreau R, Kamath PS, et al. Acute-on-chronic liver failure in cirrhosis. Nat Rev Dis Primers. 2016;2:16041.PubMedCrossRefGoogle Scholar
  88. 88.
    Davenport A, Sheikh MF, Lamb E, Agarwal B, Jalan R. Acute kidney injury in acute-on-chronic liver failure: Where does hepatorenal syndrome fit? Kidney Int. 2017;92:1058–1070.PubMedCrossRefGoogle Scholar
  89. 89.
    Arroyo V, Jalan R. Acute-on-chronic liver failure: definition, diagnosis, and clinical characteristics. Semin Liver Dis. 2016;36:109–116.PubMedCrossRefGoogle Scholar
  90. 90.
    Arora V, Maiwall R, Vijayaraghavan R, et al. Terlipressin is superior to noradrenaline in the management of acute kidney injury in acute on chronic liver failure. Hepatology. 2018;. Scholar
  91. 91.
    Piano S, Schmidt HH, Ariza X, et al. Association between grade of acute on chronic liver failure to terlipressin and albumin in patients with hepatorenal syndrome. Clin Gastroenterol Hepatol. 2018;. Scholar
  92. 92.
    Martín-Llahí M, Pepin MN, Guevara M, et al. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology. 2008;134:1352–1359.PubMedCrossRefGoogle Scholar
  93. 93.
    Alessandria C, Venon WD, Marzano A, Barletti C, Fadda M, Rizzetto M. Renal failure in cirrhotic patients: role of terlipressin in clinical approach to hepatorenal syndrome type 2. Eur J Gastroenterol Hepatol. 2002;14:1363–1368.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Frederik Nevens
    • 1
    Email author
  • Paulo Lisboa Bittencourt
    • 2
  • Minneke J. Coenraad
    • 3
  • Huiguo Ding
    • 4
  • Ming-Chih Hou
    • 5
  • Pierre-François Laterre
    • 6
  • Manuel Mendizabal
    • 7
  • Nayeli Xochiquetzal Ortiz-Olvera
    • 8
  • Julio D. Vorobioff
    • 9
  • Wenhong Zhang
    • 10
  • Paolo Angeli
    • 11
  1. 1.Department of Gastroenterology and Hepatology, University Hospitals LeuvenKU LeuvenLouvainBelgium
  2. 2.Unit of Gastroenterology and HepatologyPortuguese Hospital of SalvadorSalvadorBrazil
  3. 3.Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
  4. 4.Department of Gastroenterology and HepatologyBeijing You’an Hospital Affiliated with Capital Medical UniversityBeijingChina
  5. 5.Department of Medicine Division of GastroenterologyTaipei Veterans General HospitalTaipeiTaiwan
  6. 6.Medical-surgical Intensive Care Unit, Cliniques Universitaires Saint LucUniversité Catholique de LouvainBrusselsBelgium
  7. 7.Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
  8. 8.Department of Gastroenterology, UMAE, Hospital de Especialidades Dr. Bernardo Sepúlveda, Centro Médico Nacional Siglo XXIIMSSMexico CityMexico
  9. 9.Department of Gastroenterology and HepatologyUniversity of Rosario Medical SchoolRosarioArgentina
  10. 10.Department of Infectious Diseases, Huashan HospitalFudan UniversityShanghai ShiChina
  11. 11.Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMEDUniversity of PadovaPaduaItaly

Personalised recommendations