{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T18:40:18Z","timestamp":1792176018232,"version":"4.4.0"},"reference-count":20,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"8","license":[{"start":{"date-parts":[[2021,7,14]],"date-time":"2021-07-14T00:00:00Z","timestamp":1626220800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2021,7,14]],"date-time":"2021-07-14T00:00:00Z","timestamp":1626220800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["Liver Transpl"],"published-print":{"date-parts":[[2021,8]]},"abstract":"<jats:p>Vasoconstrictors are the treatment of choice for hepatorenal syndrome (HRS). We evaluate the real\u2010life effectiveness of a sequential vasoconstrictor regimen of midodrine\u2013octreotide followed by norepinephrine in a nonintensive care unit (non\u2010ICU) setting in the United States, where terlipressin is not available. The diagnosis of HRS and definitions of response to therapy were based on 2015 guidelines from the International Club of Ascites. In adult patients with HRS without partial or full response to oral midodrine and subcutaneous octreotide, norepinephrine was administered at a starting dose of 5\u00a0mcg\/minute, with a goal to achieve a mean arterial pressure (MAP) of 10\u00a0mm Hg above baseline. We assessed predictors of response and treatment outcomes. A total of 61 patients were administered midodrine and octreotide for the treatment of HRS, with a 28% response rate. The median MELD\u2010Na (Model for End\u2010Stage Liver Disease\u2013sodium) score was 30 (interquartile range [IQR] 24\u201035). Responders were more likely to have alcohol\u2010related liver disease and lower Acute\u2010on\u2010Chronic Liver Failure (ACLF) grade. Of the nonresponders, 20 were then administered norepinephrine, of whom 45% achieved full or partial response. Achieving an MAP increase of \u226510\u00a0mm Hg was associated with a greater probability of response. Patients who responded to norepinephrine experienced improved transplant\u2010free survival at 90\u00a0days (88% versus 27%; <jats:italic toggle=\"yes\">P<\/jats:italic>\u00a0=\u00a00.02); 5 of 20 patients experienced norepinephrine treatment\u2013related adverse events, namely arrhythmias. Norepinephrine can be effectively used in a non\u2010ICU setting as rescue therapy in patients who have not responded to midodrine and octreotide. Based on these data, we propose a practical stepwise algorithm for vasoconstrictor therapy to manage HRS in situations where terlipressin is not an option.<\/jats:p>","DOI":"10.1002\/lt.26065","type":"journal-article","created":{"date-parts":[[2021,4,10]],"date-time":"2021-04-10T03:07:07Z","timestamp":1618024027000},"page":"1095-1105","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":28,"title":["Feasibility and Effectiveness of Norepinephrine Outside the Intensive Care Setting for Treatment of Hepatorenal Syndrome"],"prefix":"10.1097","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3874-6612","authenticated-orcid":false,"given":"Allison","family":"Kwong","sequence":"first","affiliation":[{"name":"Division of Gastroenterology and Hepatology,Stanford University,Stanford,CA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3030-860X","authenticated-orcid":false,"given":"W. Ray","family":"Kim","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology,Stanford University,Stanford,CA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul Y.","family":"Kwo","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology,Stanford University,Stanford,CA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Uerica","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Pharmacy,Stanford Health Care,Stanford,CA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xingxing","family":"Cheng","sequence":"additional","affiliation":[{"name":"Division of Nephrology,Stanford University,Stanford,CA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2021,7,14]]},"reference":[{"key":"lt26065-bib-0001-20250824","first-page":"1310","article-title":"Diagnosis, prevention and treatment of hepatorenal 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