What is the recommended albumin regimen for Acute Kidney Injury (AKI) in a patient with cirrhosis?

Albumin Regimen for Acute Kidney Injury in Cirrhotic Patients

For cirrhotic patients with AKI, the recommended albumin regimen is 1 g/kg/day for 2 consecutive days initially, followed by 20-40 g daily if hepatorenal syndrome (HRS-AKI) is diagnosed, continuing until serum creatinine returns to within ≤0.3 mg/dL of baseline or for a maximum of 14 days. 1

Initial Management Algorithm

Step 1: Diagnosis and Initial Measures

• Diagnose AKI when serum creatinine increases by ≥0.3 mg/dL within 48 hours or ≥50% from baseline 1
• Immediately upon AKI diagnosis:
  • Hold diuretics and beta-blockers
  • Discontinue all nephrotoxic medications (especially NSAIDs)
  • Treat any identified precipitating factors
  • Perform diagnostic paracentesis to rule out spontaneous bacterial peritonitis 1

Step 2: Albumin Administration Based on AKI Stage

• For AKI Stage 1 with serum creatinine <1.5 mg/dL:

  • Provide volume expansion with albumin only if clinically hypovolemic 1

• For AKI Stage 1 with serum creatinine ≥1.5 mg/dL OR AKI Stage 2-3:

  • Administer albumin 1 g/kg/day (maximum 100 g/day) for 2 consecutive days 1
  • Monitor fluid status closely using vital signs and, when indicated, echocardiography or CVP 1

Step 3: Management After Initial Albumin Challenge

• If serum creatinine improves (returns to within 0.3 mg/dL of baseline):

  • Continue close monitoring
  • Follow up every 2-4 days during hospitalization and every 2-4 weeks after discharge 1

• If serum creatinine remains elevated >2× baseline after albumin challenge:

  • Diagnose HRS-AKI if other criteria are met
  • Continue albumin at 20-40 g daily
  • Add vasoconstrictors (terlipressin, norepinephrine, or midodrine plus octreotide) 1
  • Continue this regimen until serum creatinine returns to within ≤0.3 mg/dL of baseline for 2 consecutive days or for a maximum of 14 days 1

Important Considerations

Diagnostic Criteria for HRS-AKI

• Diagnosis of cirrhosis and ascites
• No response after 2 days of diuretic withdrawal and albumin (1 g/kg)
• Absence of shock
• No current/recent use of nephrotoxic drugs
• No macroscopic signs of structural kidney injury (proteinuria >500 mg/day, microhematuria, abnormal renal ultrasound) 1

Monitoring for Complications

• Risk of pulmonary edema: Monitor fluid status closely as excessive albumin can cause respiratory failure 1
• Risk of ischemic side effects: When using vasoconstrictors with albumin, monitor for angina, digital ischemia, and intestinal ischemia 1

Efficacy Considerations

• Higher total doses of albumin may improve 180-day survival but increase risk of respiratory failure 1
• Urinary NGAL can help differentiate HRS-AKI from acute tubular necrosis, with values <220-244 μg/g creatinine suggesting HRS-AKI 1
• Early administration of albumin is crucial as higher pretreatment serum creatinine is associated with treatment failure 1

Special Situations

• Spontaneous bacterial peritonitis: Add albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 to antibiotic therapy 1
• Large volume paracentesis: Administer albumin at 6-8 g/L of ascites removed 1
• Tense ascites causing AKI: Therapeutic paracentesis with albumin replacement may improve renal function 1

While some recent research questions the association between albumin use and improved outcomes in cirrhotic patients with AKI 2, the most current guidelines strongly recommend albumin as the plasma expander of choice due to its volume-expanding, anti-inflammatory, and non-oncotic properties 1.