When to Administer Lasix and Albumin in Oliguric AKI
Do not use furosemide (Lasix) to prevent or treat oliguric AKI except for managing volume overload; albumin infusion is indicated only in cirrhotic patients with AKI and intravascular volume depletion, not in general AKI populations. 1
General AKI Management (Non-Cirrhotic Patients)
Furosemide Use
- Furosemide should NOT be used to prevent AKI or to convert oliguric to non-oliguric AKI 1
- The only indication for diuretics in AKI is management of volume overload (pulmonary edema, severe fluid overload) 1
- Current evidence shows furosemide does not reduce mortality in AKI patients 2
- High-dose furosemide may actually increase renal oxidative stress, particularly in severe AKI, potentially causing harm 3
Albumin Use
- Albumin is NOT recommended for general AKI management 1
- In non-cirrhotic patients, isotonic crystalloids (not colloids like albumin) should be used for volume expansion 1
- Albumin has been associated with harm in traumatic brain injury patients and should be avoided in that setting 1
Cirrhotic Patients with AKI (Special Population)
Initial Assessment and Albumin Challenge
After withdrawing diuretics and treating precipitating factors (infections), administer IV albumin 1 g/kg body weight (maximum 100 g/day) for 48 hours 1
- This albumin challenge serves both diagnostic and therapeutic purposes 1
- Albumin is superior to crystalloids in cirrhotic patients because it more effectively restores effective arterial blood volume 1
- Lack of response to this albumin challenge is a diagnostic criterion for hepatorenal syndrome-AKI (HRS-AKI) 1
When to Add Vasoconstrictors with Albumin
Vasoconstrictors plus albumin (20-40 g/day) are indicated ONLY for Stage 2 or greater HRS-AKI, NOT for other forms of AKI in cirrhosis 1
Specific Criteria:
- Stage 2 or 3 HRS-AKI (creatinine increase >2-3 times baseline) 1
- After failed albumin challenge (no improvement after 48 hours of albumin 1 g/kg/day) 1
- Exclude other AKI causes: no shock, no nephrotoxic drugs, no parenchymal kidney disease 1
- Creatinine threshold: Start early when creatinine is 2.25-5 mg/dL; patients with creatinine >5 mg/dL have low response rates 1
Vasoconstrictor Options:
- Terlipressin (0.5-2.0 mg IV q6h or continuous infusion 2 g/24h IV) is first-line 1
- Norepinephrine as alternative, especially in shock patients (requires ICU) 1
- Octreotide/midodrine combination where other agents unavailable 1
Critical Caveats for Albumin in Cirrhosis
Monitor carefully for volume overload and pulmonary edema 1
- Routine fixed-dose albumin may cause pulmonary edema, particularly in patients with cirrhotic cardiomyopathy or diastolic dysfunction 1
- The optimal duration of albumin with vasoconstrictors is unclear; consider stopping after initial 1-2 days based on volume status 1
- Respiratory failure occurred in 8% of patients receiving terlipressin, especially with higher albumin volumes 1
When NOT to Use Vasoconstrictors in Cirrhosis
Do NOT use vasoconstrictors for:
- Stage 1 AKI (no current recommendation) 1
- Non-HRS forms of AKI (acute tubular necrosis, prerenal azotemia) 1
- Uncomplicated ascites (insufficient evidence for midodrine as diuretic adjuvant) 1
- ACLF-3 patients (contraindication for terlipressin) 1
- Major cardiopulmonary or vascular disease 1
Furosemide in Cirrhotic AKI
Withdraw diuretics including furosemide when AKI develops in cirrhotic patients 1
- Diuretics should be stopped as part of initial AKI management 1
- Evidence is insufficient to use furosemide with midodrine in cirrhotic ascites 1
Algorithm Summary
- Identify patient population: Cirrhotic vs. non-cirrhotic
- Non-cirrhotic AKI: No albumin; furosemide only for volume overload 1
- Cirrhotic AKI: