What is the management for a patient with dengue hepatitis and hypoalbuminemia (low albumin level)?

Management of Dengue Hepatitis with Hypoalbuminemia (Albumin 2.5 g/dL)

In a patient with dengue hepatitis and albumin of 2.5 g/dL, focus on aggressive fluid resuscitation with isotonic crystalloids, close monitoring for plasma leakage and shock, and avoid albumin infusion as it is not indicated for dengue-related hypoalbuminemia.

Understanding Hypoalbuminemia in Dengue

Low albumin in dengue reflects acute inflammation and plasma leakage, not nutritional deficiency or an indication for albumin replacement. 1 Albumin levels decline during acute phase inflammatory response due to alterations in hepatic protein synthesis, and hypoalbuminemia in dengue is an inflammatory marker associated with disease severity rather than a target for correction. 1

• Albumin 2.5 g/dL indicates severe dengue with significant plasma leakage. 2 Lower albumin concentrations at admission are associated with higher risk of ICU transfer and worse outcomes. 1
• Hypoalbuminemia (50.8%) and albumin:globulin ratio reversal are significantly more common in severe dengue. 3
• Serum albumin quantification increases detection of vascular permeability abnormalities in 43% of cases where hemoconcentration is less than 20%. 4

Immediate Assessment and Monitoring

Check for shock indicators immediately: tachycardia, hypotension (systolic BP <90 mmHg), poor capillary refill (>2 seconds), altered mental status, cold extremities, and narrow pulse pressure (<20 mmHg). 5

• Monitor for warning signs: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, and rising hematocrit with rapidly falling platelet count. 6, 5
• Obtain daily complete blood count to track platelet counts and hematocrit levels. 6
• Monitor liver function tests: SGOT/SGPT elevation occurs in 74.2% of dengue patients and correlates with disease severity. 3
• Check INR and bilirubin, as these predict development of liver failure in dengue. 7

Fluid Management Strategy

If No Shock Present:

• Target 2,500-3,000 mL daily oral intake using water, oral rehydration solutions, cereal-based gruels, soup, or rice water. 5
• Avoid soft drinks due to high osmolality. 5
• This aggressive oral hydration reduces hospitalization rates. 5

If Dengue Shock Syndrome Present:

Administer 20 mL/kg isotonic crystalloid as rapid bolus over 5-10 minutes. 6, 5

• Reassess immediately after each bolus for capillary refill, skin mottling, extremity warmth, peripheral pulses, mental status, and urine output. 5
• Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists. 5
• Monitor hematocrit closely—rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation. 5

If Refractory Shock Despite Adequate Fluid Resuscitation:

• Switch to inotropic support rather than continuing aggressive fluid administration. 5
• Titrate epinephrine as first-line vasopressor for cold shock with hypotension. 5
• Use norepinephrine as first-line vasopressor for warm shock with hypotension. 5

Why Albumin Infusion is NOT Indicated

The evidence for albumin use comes from cirrhosis with spontaneous bacterial peritonitis, NOT dengue. 1 The albumin guidelines cited (EASL, AASLD) specifically address cirrhotic patients with ascites and SBP, where albumin prevents hepatorenal syndrome. 1

• Albumin infusion is indicated for cirrhosis with SBP (1.5 g/kg at diagnosis, 1 g/kg on day 3) to prevent hepatorenal syndrome. 1 This does NOT apply to dengue.
• In dengue, hypoalbuminemia results from acute inflammation and capillary leak, not from the same pathophysiology as cirrhosis. 1
• No dengue guidelines recommend albumin replacement for low albumin levels. 6, 5
• Targeting specific albumin levels may be associated with pulmonary edema and fluid overload. 1

Pain and Fever Management

Use acetaminophen at standard doses only. 6, 5

• Never use aspirin or NSAIDs due to high bleeding risk. 6, 5
• This applies to all patients where dengue cannot be excluded. 6

Management of Bleeding Complications

If significant bleeding occurs with this degree of hypoalbuminemia:

• Maintain hemoglobin at minimum 10 g/dL as oxygen delivery depends on hemoglobin concentration. 5
• Blood transfusion may be necessary for significant bleeding. 6
• Patients with elevated SGOT (93.8%) and SGPT (81.2%) have higher incidence of bleeding manifestations. 3

Monitoring for Multiorgan Failure

With albumin 2.5 g/dL, this patient is at high risk for multiorgan failure:

• Nonhematological organ dysfunction (cardiovascular, respiratory, neurological) is the primary determinant of outcome in severe dengue. 2
• Low serum albumin on ICU admission (2.9 ± 0.3 g/dL in nonsurvivors vs 3.4 ± 0.7 g/dL in survivors) is associated with worse outcomes. 2
• Positive cumulative fluid balance at 72 hours (6.2 L in nonsurvivors vs 3.5 L in survivors) is associated with mortality. 2

Critical Pitfalls to Avoid

• Do not administer albumin infusion based on low serum albumin alone—this is not indicated in dengue and may cause fluid overload. 1
• Do not delay fluid resuscitation in patients showing signs of shock. 6
• Do not continue aggressive fluid administration if shock persists despite adequate resuscitation—switch to vasopressors. 5
• Do not use aspirin or NSAIDs under any circumstances. 6, 5

Discharge Criteria

Patient can be discharged when:

• Afebrile for ≥48 hours without antipyretics. 6
• Resolution or significant improvement of symptoms. 6
• Stable hemodynamic parameters for ≥24 hours without support. 6
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults). 6
• Laboratory parameters returning to normal ranges. 6