When to administer albumin in patients with hepatorenal syndrome?

Albumin Administration in Hepatorenal Syndrome

Albumin should be administered in hepatorenal syndrome (HRS) as a volume challenge at a dose of 1 g/kg body weight (maximum 100 g/day) for two consecutive days upon diagnosis, followed by 20-40 g/day during vasoconstrictor therapy. 1, 2

Diagnostic Context for Albumin Administration

Albumin administration in HRS should follow this algorithm:

1. Initial diagnosis of AKI in cirrhosis:

   • Withdraw diuretics and treat precipitating factors
   • Administer albumin 1 g/kg body weight (maximum 100 g/day) for 48 hours as volume challenge 1
   • Reassess kidney function after 48 hours

2. If no improvement after volume challenge:

   • If criteria for HRS-AKI are met (Stage 2 or greater AKI with no response to volume expansion)
   • Start vasoconstrictor therapy with continued albumin support

Albumin Dosing with Vasoconstrictors

When administering vasoconstrictors for HRS-AKI treatment:

• Initial albumin dose: 1 g/kg on day 1 (maximum 100 g) 3
• Maintenance dose: 20-40 g/day throughout the duration of vasoconstrictor therapy 1
• Duration: Continue until complete response (serum creatinine returns to within 0.3 mg/dL of baseline) or for maximum 14 days 1, 2

Specific Clinical Scenarios

HRS-AKI (formerly Type 1 HRS)

• Albumin is a mandatory component of treatment alongside vasoconstrictors 1
• The FDA-approved CONFIRM trial used albumin 1 g/kg on day 1 followed by 20-40 g/day with terlipressin 3
• Meta-analysis shows a dose-response relationship between cumulative albumin dose and survival, with higher doses associated with better outcomes 4

HRS-NAKI (formerly Type 2 HRS)

• Less evidence for albumin use in this setting
• Consider albumin administration based on individual patient needs and central venous pressure 5

Choice of Vasoconstrictor

Albumin should always be paired with a vasoconstrictor for HRS treatment:

1. First-line: Terlipressin plus albumin (29.1% response rate vs. 15.8% with placebo) 3, 6
2. Alternative: Norepinephrine plus albumin (similar efficacy to terlipressin) 1
3. If others unavailable: Midodrine plus octreotide with albumin (less effective, 28.6% response vs. 70.4% with terlipressin) 7

Monitoring During Albumin Administration

• Monitor for signs of volume overload and pulmonary edema
• Assess cardiovascular parameters regularly
• Evaluate response by measuring serum creatinine daily
• Consider discontinuation if severe adverse effects occur (fluid overload, pulmonary edema)

Important Caveats

• Avoid albumin in patients with: Severe pulmonary edema, severe cardiac dysfunction 1
• Response rates are lower in patients with: Higher baseline serum creatinine, advanced liver disease 2, 6
• Albumin alone is insufficient: A randomized trial showed only 8.7% response with albumin alone versus 43.5% with terlipressin plus albumin 8
• Timing matters: Earlier treatment initiation is associated with better outcomes 2

Albumin administration is a cornerstone of HRS management, but must be combined with vasoconstrictors to effectively improve renal function and survival. The evidence strongly supports the use of albumin at the specified doses to optimize outcomes in this high-mortality condition.