How do you approach the decision to use terlipressin in a patient with hepatorenal syndrome type 1, AKI, and a history of heart failure given its potential cardiovascular effects?

I usually do a full workup to make sure the etiology of AKI is type 1 HRS. Would also make sure bleeding or infection not complicating the clinical scenario. This is not as simple as it seems, especially in the setting of primary heart failure as a complicating factor, and requires thorough thinking and testing. HRS itself exacerbates heart failure by adding a distributive vasodilatory state. Once diagnosis is made according to the most recent consensus guidelines, would try albumin or albumin with midodrine/octreotide. Then can move to Vasopressin to help with renal perfusion as a last resort.

In the US, we use Vasopressin in lieu of Terlipressin.