S2860 Uncovering Gaps in Evidence-Based Diagnosis and Treatment of Hepatorenal Syndrome – Acute Kidney Injury (HRS-AKI): Results From a Nationwide Survey

Introduction: HRS-AKI is a rapidly progressive and often fatal complication of cirrhosis that requires timely diagnosis and treatment. Recent advances including the FDA approval and first-line recommendation of terlipressin within updated clinical guidelines have reshaped management, yet uptake in practice remains unclear. Methods: A nationwide survey was disseminated in January 2025 via email to 6,568 healthcare providers (HCPs) involved in the care of HRS-AKI, yielding a 2.3% completion rate. Survey items explored HCP knowledge, confidence, current practices, and barriers to evidence-based diagnosis and management. Chi-square tests evaluated statistical differences between practice settings. Results: A total of 153 HCPs completed the survey, including nephrologists (35%), gastroenterologists (19%), hepatologists (14%), intensivists (14%), hospitalists (8%) and other team members (10%). The median time in practice was 18 years. Most practiced in academic medical centers (46%) or community hospitals (45%), with 68% spending at least half their time in inpatient care. While most HCPs reported high confidence in diagnosing HRS-AKI (80%), and correctly identified guideline-based criteria for AKI (83%), diagnostic and management practices varied by setting. Community HCPs were less likely than academic HCPs to require albumin use prior to diagnosis (45% vs 69%, P = 0.004), and reported less familiarity with (42% vs 61%, P = 0.028) and access to (41% vs 70%, P = 0.001) terlipressin. Across both settings, only about one quarter reported terlipressin as their most used vasoconstrictor (31% academic vs 20% community, P = 0.148). Both groups indicated that diagnostic delays (54% academic vs 33% community), uncertainty about optimal management (35% vs 36%), and lack of institutional protocols (34% vs 35%) were the most significant barriers to HRS treatment. Similarly, both cited limited access (30% academic vs 46% community), formulary restrictions (30% vs 41%), and safety concerns (34% vs 29%) as predominant reasons for not using terlipressin. Conclusion: Findings reveal gaps between clinical guidelines and real-world practice, especially in community settings with limited access to terlipressin. However, low utilization, even in academic centers, suggests barriers beyond access, such as unfamiliarity, delayed diagnosis or institutional inertia. These results underscore the need for targeted education and system-level support to improve timely, evidence-based HRS-AKI care.