What is the recommended dose of albumin (Human Albumin) in Hepatorenal Syndrome (HRS)?

Albumin Dosing in Hepatorenal Syndrome

For HRS-AKI, administer IV albumin at 1 g/kg (maximum 100 g) on day 1, followed by 20-40 g daily in combination with vasoconstrictors, continuing until serum creatinine returns to within 0.3 mg/dL of baseline or for up to 14 days. 1

Initial Loading Dose

• Day 1-2: Administer 1 g/kg IV albumin (up to maximum 100 g/day) for the first 2 days when HRS-AKI is diagnosed and serum creatinine shows doubling from baseline despite volume repletion 1
• This loading dose should be given before or concurrent with initiation of vasoconstrictor therapy (terlipressin, norepinephrine, or midodrine/octreotide combination) 1, 2

Maintenance Dosing

• Day 3 onwards: Continue with 20-40 g/day IV albumin 1, 3
• Maintain this dose throughout the treatment course, which typically extends until reversal of HRS or for maximum 14 days 1, 3
• The optimal duration of albumin administration remains somewhat unclear, but treatment should continue either until 24 hours following return of serum creatinine to within ≤0.3 mg/dL of baseline for 2 consecutive days, or for total of 14 days 1

Critical Monitoring Considerations

Volume overload is a significant risk with albumin therapy, particularly in patients with ACLF-3 or underlying cirrhotic cardiomyopathy. 1

• Monitor closely for pulmonary edema and respiratory failure, as these complications occurred in 8% of patients receiving terlipressin with albumin in recent trials 1
• Use urine output, vital signs, and when indicated, echocardiography or central venous pressure monitoring to assess fluid status 1
• Consider the total amount of albumin administered prior to initiation of vasoconstrictors, as excessive pretreatment volume may increase respiratory complications 1

Special Circumstances

Large-Volume Paracentesis

• When performing paracentesis >5L, administer albumin at 6-8 g per liter of ascites removed 1
• In patients with ACLF, give 6-8 g/L regardless of volume removed 1

Spontaneous Bacterial Peritonitis

• Use 1.5 g/kg on day 1 and 1 g/kg on day 3 when SBP is present, particularly in patients with serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL 1

When to Discontinue Albumin

Stop albumin administration if anasarca (severe peripheral edema with fluid overload) develops, while continuing vasoconstrictors. 4

• The development of anasarca indicates significant volume overload that will not benefit from continued albumin 4
• Vasoconstrictors (terlipressin, norepinephrine, or octreotide/midodrine) should be maintained even after albumin discontinuation 4, 2
• Implement diuretic therapy and sodium restriction (<2g/day) for volume management 4

Evidence Quality and Comparative Effectiveness

The albumin dosing regimen (1 g/kg followed by 20-40 g/day) is supported by Grade 1A evidence from the American Society of Transplantation 1. This dosing strategy has been consistently used across multiple randomized trials demonstrating efficacy in HRS reversal 5, 6. Studies show that terlipressin plus albumin at these doses achieves HRS reversal in 43.5-70.4% of patients 5, 6, significantly superior to albumin alone (8.7%) 6 or midodrine/octreotide combinations (28.6%) 5.

Common Pitfalls to Avoid

• Do not use albumin monotherapy without vasoconstrictors in HRS-AKI, as response rates are only 8.7% compared to 43.5% with combination therapy 6
• Do not continue albumin indefinitely in patients with refractory ascites outside the specific indications of paracentesis, SBP, or active HRS-AKI treatment 4
• Do not administer albumin for non-SBP infections in cirrhosis, as this increases pulmonary edema risk without mortality benefit 1
• Avoid excessive fluid restriction in hyponatremic patients; limit fluids to <1000 mL/day only if sodium <125 mEq/L 4