What is the recommended dose of albumin (Albumin) for the management of Hepatorenal Syndrome (HRS) Acute Kidney Injury (AKI)?

Albumin Dosing in Hepatorenal Syndrome Acute Kidney Injury

For hepatorenal syndrome acute kidney injury (HRS-AKI), 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, 2

Initial Diagnosis and Management Algorithm

1. Diagnosis of HRS-AKI requires:

   • Cirrhosis with ascites
   • AKI according to ICA-AKI criteria
   • No response after diuretic withdrawal and volume expansion
   • Absence of shock
   • No recent use of nephrotoxic drugs
   • No signs of structural kidney injury 2

2. Initial Volume Expansion:

   • Withdraw all diuretics
   • Administer albumin at 1 g/kg body weight (maximum 100 g/day) for two consecutive days 2, 1
   • Assess response by measuring serum creatinine daily

3. Response Assessment:

   • Complete response: Return of serum creatinine to within 0.3 mg/dL of baseline
   • Partial response: Regression of AKI stage with serum creatinine ≥0.3 mg/dL above baseline
   • No response: No improvement in renal function 1

Vasoconstrictor Therapy with Albumin

If no response to initial volume expansion, initiate vasoconstrictor therapy with continued albumin support:

1. First-line treatment: Terlipressin plus albumin

   • Terlipressin: 0.5-2.0 mg IV every 4-6 hours or continuous infusion (2-12 mg/24h)
   • Albumin: 20-40 g/day during vasoconstrictor therapy 1

2. Alternative treatments (if terlipressin unavailable):

   • Norepinephrine (0.5-3.0 mg/h continuous IV infusion) plus albumin
   • Midodrine (7.5-12.5 mg orally TID) plus octreotide (100-200 μg SQ TID) with albumin 2, 1

Monitoring During Treatment

• Daily assessment of serum creatinine
• Monitor for signs of volume overload and pulmonary edema
• Regular assessment of cardiovascular parameters
• Watch for ischemic complications with vasoconstrictors 1

Duration of Therapy

• Continue treatment until complete response or maximum 14 days 1
• If no response after 4 days of maximum dose therapy, consider treatment failure

Important Considerations

• Maximum daily albumin dose: Do not exceed 100 g/day to avoid pulmonary edema 2
• Contraindications for albumin: Severe pulmonary edema or severe cardiac dysfunction 1
• Predictors of response: Lower baseline serum creatinine is associated with better response to therapy 3
• Adverse effects: Monitor for fluid overload, which can occur in up to 43% of patients treated with terlipressin and albumin 1, 4

Special Situations

• Spontaneous bacterial peritonitis (SBP): Albumin should be administered at 1.5 g/kg on day 1 and 1 g/kg on day 3 in addition to antibiotics 2
• Large volume paracentesis (>5L): Administer albumin at 6-8 g/L of ascites removed 2

Early initiation of treatment is crucial for improving outcomes, as response rates are significantly higher with lower baseline serum creatinine values 3, 5. A standardized approach to albumin administration has been associated with improved treatment response rates and lower need for renal replacement therapy 6.