Abstract: TH-PO0772
Droxidopa as a Novel Adjunct in Hepatorenal Syndrome-AKI (HRS-AKI)
Session Information
- AKI: Critical Care, CKRT, Cardiorenal Syndromes, and Clinical Outcomes
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Author
- Tey, CS Jason, Legacy Emanuel Medical Center, Portland, Oregon, United States
Introduction
HRS-AKI carries high mortality in cirrhosis, with vasoconstrictor-albumin as mainstay therapy to counteract the underlying splanchnic vasodilation, systemic arterial underfilling, and impaired kidney perfusion. Terlipressin is first-line but limited by cost and availability. Norepinephrine (NE) is similarly effective but requires ICU-level care, while midodrine-octreotide is less effective. This case highlights the use of droxidopa, an oral NE precursor, in HRS-AKI.
Case Description
A 64-year-old woman with metabolic dysfunction-associated steatohepatitis cirrhosis presented with serum creatinine (sCr) of 3.4 mg/dL (baseline of 1.7 in prior month). Workup excluded infection and shock. Recent 11-liter paracentesis with inadequate albumin replacement causing circulatory dysfunction was the likely precipitant. Albumin challenge improved sCr to 2.1 but rebounded to 2.3-2.4 after discontinuation, raising concern for HRS-AKI and supported by bland urinalysis, absent structural disease, and urine sodium <10. Midodrine-octreotide was started with albumin resumption but without improvement. Due to terlipressin unavailability, NE was initiated in the ICU and improved sCr to 1.6-1.7. On NE wean, sCr rebounded to 2.1-2.2. Although this coincided with new bacteriuria, antibiotic treatment did not improve sCr. Droxidopa was started at 100 mg TID and uptitrated to 200 mg TID, enabling NE discontinuation, with sCr stabilizing at 1.9-2.0. Therapies were deescalated prior to discharge without recurrent AKI, and she was bridged to liver transplant evaluation.
Discussion
Droxidopa is converted to NE by DOPA decarboxylase throughout the body. Data on its use in HRS-AKI remain scarce, although preclinical cirrhotic rat models showed improved arterial pressure, diuresis, and natriuresis. In this case, the worsening sCr on NE wean and partial recovery and stabilization after droxidopa initiation are notable. Studies in orthostatic hypotension showed greater local kidney than plasma droxidopa conversion while still achieving systemic pressor effects. Whether this local kidney conversion is reduced in kidney impairment remains unclear but could explain the partial rather than complete sCr improvement, suggesting a role for higher dosing. This case highlights droxidopa as a potential novel, low-cost, oral adjunct in HRS-AKI. Further investigations to evaluate its dosing, safety, and efficacy are warranted in this population.