What is the recommended dose of albumin (Human Albumin) for patients with Hepatorenal Syndrome (HRS)?

Albumin Dosing in Hepatorenal Syndrome (HRS)

For patients with hepatorenal syndrome, intravenous albumin should be administered at a dose of 1 g/kg body weight per day for two consecutive days (maximum 100 g/day), followed by 20-40 g/day during vasoconstrictor therapy. 1

Initial Albumin Administration for Diagnosis and Treatment

Diagnostic Volume Challenge

• Administer 1 g/kg body weight of albumin IV daily for 2 consecutive days (maximum 100 g/day) 1
• This initial albumin challenge serves two purposes:
  1. Diagnostic: Helps differentiate HRS from pre-renal AKI (volume-responsive)
  2. Therapeutic: Provides initial volume expansion to improve renal perfusion

Maintenance Albumin Therapy

• After the initial 2-day challenge, continue albumin at 20-40 g/day in combination with vasoconstrictors 1
• Continue until:
  • Serum creatinine returns to within 0.3 mg/dL of baseline for 2 consecutive days, OR
  • Maximum treatment duration of 14 days is reached 1

Monitoring During Albumin Administration

• Fluid status: Monitor closely for signs of pulmonary edema, especially in patients with cardiac dysfunction 1
• Vital signs: Regular assessment of blood pressure and heart rate
• Renal function: Daily serum creatinine to assess response
• Electrolytes: Monitor for hyponatremia or hypernatremia

Evidence Supporting Albumin Use in HRS

Multiple guidelines strongly support the use of albumin in HRS. The International Club of Ascites consensus recommendations 1 and the American Society of Transplantation 1 both recommend the same dosing regimen. This is further reinforced by the American Association for the Study of Liver Diseases (AASLD) 1 and European Association for the Study of the Liver (EASL) 1.

Studies have demonstrated that the combination of albumin with vasoconstrictors is superior to vasoconstrictors alone. In a prospective study, patients receiving terlipressin plus albumin had a 77% response rate compared to only 25% in those receiving terlipressin alone 2.

Important Clinical Considerations

• Maximum daily dose: Do not exceed 100 g of albumin per day 1
• Treatment failure: If no response after 3-4 days (serum creatinine not decreasing by at least 25%), consider increasing vasoconstrictor dose rather than albumin dose 1
• Contraindications: Use cautiously in patients with:
  • History of pulmonary edema
  • Severe cardiac dysfunction
  • Severe hyponatremia

Vasoconstrictor Selection with Albumin

Albumin should always be combined with a vasoconstrictor:

1. First-line: Terlipressin (0.5-2.0 mg IV every 4-6 hours or continuous infusion of 2-12 mg/24h) plus albumin 1
2. Alternatives when terlipressin is unavailable:
   • Norepinephrine (0.5-3.0 mg/h continuous IV infusion) plus albumin 1
   • Midodrine (7.5-12.5 mg orally TID) plus octreotide (100-200 μg SQ TID) plus albumin 1

Pitfalls to Avoid

• Inadequate initial dosing: Failure to provide the full 1 g/kg for 2 days may result in misdiagnosis of HRS
• Delayed treatment: Early administration improves outcomes; higher baseline creatinine is associated with treatment failure 3
• Monotherapy: Using albumin without vasoconstrictors is ineffective 1
• Excessive albumin: Overuse can lead to pulmonary edema; monitor fluid status carefully 1
• Premature discontinuation: Continue treatment until resolution or for the full 14-day course if partial response

Remember that while albumin therapy is crucial, it's just one component of HRS management. Identifying and treating precipitating factors (infections, nephrotoxic drugs, etc.) and discontinuing diuretics are equally important steps in the management algorithm.