Can albumin (human albumin) therapy be stopped in patients with hepatorenal syndrome and anasarca?

Management of Albumin Therapy in Hepatorenal Syndrome with Anasarca

Albumin therapy should be discontinued in patients with hepatorenal syndrome who develop anasarca, as continuing albumin infusions in this setting may worsen fluid overload without providing additional benefit to renal function. 1

Rationale for Discontinuing Albumin in Anasarca

• Albumin administration is primarily beneficial in specific clinical scenarios for patients with liver disease, but has limited utility in the management of refractory ascites once anasarca develops 1
• The American Association for the Study of Liver Diseases guidelines indicate insufficient data to recommend long-term use of albumin infusions outside the setting of large-volume paracentesis in patients with refractory ascites 1
• When severe peripheral edema (anasarca) develops, it indicates significant fluid overload that will not be effectively managed with continued albumin administration 1

Specific Indications for Albumin in Liver Disease

Albumin therapy remains indicated in specific scenarios despite discontinuation in anasarca:

• Prevention of post-paracentesis circulatory dysfunction during large-volume paracentesis (>5L) at a dose of 6-8g per liter of ascites removed 1
• Prevention of renal failure in spontaneous bacterial peritonitis 1
• Initial management of hepatorenal syndrome with vasoconstrictors (terlipressin, noradrenaline) at a dose of 1g/kg on day 1 (maximum 100g) followed by 20-40g/day 2, 3, 4

Management Algorithm for Hepatorenal Syndrome with Anasarca

1. Assess volume status and severity of anasarca

   • Document extent of peripheral edema, ascites, and pleural effusions 1
   • Monitor daily weights and fluid balance 1

2. Discontinue albumin therapy when anasarca develops 1

3. Implement alternative management strategies:

   • Continue vasoconstrictors (terlipressin or noradrenaline) without albumin 2, 3
   • Consider diuretic therapy for volume overload management 1
   • Maintain sodium restriction (<2g/day) 1

4. Consider renal replacement therapy if refractory volume overload persists despite above measures 3

5. Expedite liver transplantation evaluation as the definitive treatment for hepatorenal syndrome 2, 3

Important Considerations and Pitfalls

• Albumin discontinuation should not affect the continued use of vasoconstrictors (terlipressin or noradrenaline) for hepatorenal syndrome management 2, 3
• Avoid excessive fluid restriction in patients with hyponatremia; limit fluid intake to <1000mL/day only if serum sodium <125 mEq/L 1
• Monitor for worsening renal function after albumin discontinuation and adjust management accordingly 2, 3
• The development of anasarca in hepatorenal syndrome indicates poor prognosis and should prompt urgent consideration for liver transplantation 2, 3

Evidence Quality Assessment

• The recommendation to discontinue albumin in anasarca is based on expert opinion and clinical practice guidelines rather than randomized controlled trials 1
• The evidence for albumin use in specific scenarios (paracentesis, spontaneous bacterial peritonitis) is stronger than for its continued use in anasarca 1
• Most clinical trials of hepatorenal syndrome treatment have not specifically addressed management in the setting of anasarca 5, 6