Author information

¹Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA.

²Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA.

³Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA.

⁴Department of Medicine, University of California-San Francisco, San Francisco, California, USA.

⁵Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

⁶Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain.

⁷Fundació Clínic per la Recerca Biomèdica-Institut d'Investigació Biomèdica August Pi-Sunyer (IDIBAPS), Barcelona, Spain.

⁸Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.

⁹Department of Medicine, Unit of Internal Medicine and Hepatology, University of Padua, Italy.

¹⁰Baylor University Medical Center, Dallas, Texas, USA.

¹¹Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA.

Abstract

Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a severe complication of cirrhosis that carries a poor prognosis. The recent Food and Drug Administration approval of terlipressin has substantial implications for managing HRS-AKI and liver allocation in the United States. Terlipressin has been available in Europe for over a decade, and several countries have adapted policy changes such as Model for End-Stage Liver Disease (MELD) score "lock" for HRS-AKI. In this article, we outline the European experience with terlipressin use and explore the question of whether terlipressin treatment for HRS-AKI should qualify for the MELD score "lock" in the United States in those who respond to therapy. Arguments for the MELD lock include protecting waitlist priority for terlipressin responders or partial responders who may miss offers due to MELD reduction in the terlipressin treatment window. Arguments against MELD lock include the fact that terlipressin may produce a durable response and improve overall survival and that equitable access to terlipressin is not guaranteed due to cost and availability. We subsequently discuss the proposed next steps for studying terlipressin implementation in the United States. A successful approach will require the involvement of all major stakeholders and the mobilization of our transplant community to spearhead research in this area.