What is the recommended IV human albumin (Intravenous Human Albumin) regimen for patients with acute decompensated liver cirrhosis on day 1 and day 3?

IV Human Albumin Regimen for Acute Decompensated Liver Cirrhosis

Recommended Dosing Protocol

For acute decompensated cirrhosis with acute kidney injury (AKI), administer 1 g/kg of IV albumin (maximum 100 g) on day 1, followed by 20-40 g/day on subsequent days when treating with vasoconstrictors for hepatorenal syndrome. 1

Context-Specific Albumin Dosing

For AKI Without Specific Complications

• Day 1: Administer 1 g/kg of body weight (maximum 100 g/day) as volume challenge after withdrawing diuretics and treating precipitating factors 1
• Day 2: Continue 1 g/kg if needed to complete the 48-hour volume challenge 1
• Ongoing therapy: If hepatorenal syndrome (HRS-AKI) Stage 2 or greater is diagnosed, continue with 20-40 g/day in combination with vasoconstrictors 1

The optimal duration of albumin beyond the initial 48-hour period remains unclear, but treatment should continue until complete response (creatinine <1.5 mg/dL) or for maximum 14 days 1

For Spontaneous Bacterial Peritonitis (SBP)

The established regimen differs significantly from general AKI management:

• Day 1: 1.5 g/kg within 6 hours of SBP diagnosis 1, 2
• Day 3: 1.0 g/kg 1, 2

This dosing is particularly beneficial for patients with serum bilirubin >4 mg/dL or creatinine >1.0 mg/dL, reducing AKI risk by 54% and mortality by 34% 1, 3

For Large-Volume Paracentesis

• Administer 6-8 g of albumin per liter of ascites removed, given after the procedure is completed 1, 2
• This applies only when >5 liters are removed 3

Critical Dosing Considerations

Maximum Safe Dose

Do not exceed 87.5-100 g in the initial loading period, as doses above this threshold are associated with worse outcomes due to fluid overload, particularly pulmonary edema 4, 1. The 2024 AASLD guidelines specifically note that targeting specific albumin levels led to significantly higher rates of pulmonary edema and fluid overload 1

Formulation and Administration

• Use 20% or 25% albumin solution 2, 5
• For continuous therapy with vasoconstrictors, the mean dose is 20-40 g/day 1
• Monitor central venous pressure to prevent circulatory overload, though CVP is imperfect for volume assessment 1

When NOT to Use This Regimen

Albumin should NOT be administered in the following scenarios:

• Uncomplicated ascites without AKI, SBP, or large-volume paracentesis 1
• Infections other than SBP (associated with more pulmonary edema without mortality benefit) 1
• Routine volume resuscitation in critically ill cirrhotic patients 2
• Treatment of hypoalbuminemia alone 2, 5

Important Clinical Pitfalls

Volume Overload Risk

The most significant complication is fluid overload, particularly with higher doses or in patients with cardiac dysfunction 5, 1. Careful monitoring is essential, especially when doses approach or exceed 87.5 g 4

Patient Selection Matters

The evidence supporting albumin is strongest for:

• HRS-AKI Stage 2 or greater (not Stage 1) 1
• SBP with elevated creatinine or bilirubin 1
• Large-volume paracentesis >5 liters 3

For general acute decompensation without these specific complications, the evidence is weaker and albumin may not improve mortality 6, 7

Contraindications to Vasoconstrictor Therapy

If using albumin with vasoconstrictors for HRS-AKI, screen for cardiovascular disease with electrocardiogram before starting terlipressin, as cardiovascular complications occur in up to 45% of patients 1

Practical Algorithm

1. Identify the specific complication: AKI, SBP, or large-volume paracentesis
2. For AKI: Start 1 g/kg (max 100 g) on day 1, continue for 48 hours
3. If HRS-AKI diagnosed: Add vasoconstrictors and continue albumin 20-40 g/day
4. For SBP: Use 1.5 g/kg day 1, then 1.0 g/kg day 3 (different from AKI dosing)
5. Monitor closely: Watch for fluid overload, especially if total dose approaches 87.5-100 g
6. Duration: Continue until creatinine <1.5 mg/dL or maximum 14 days 1

The key distinction is that acute decompensation with AKI uses a different regimen (1 g/kg × 2 days, then 20-40 g/day) compared to SBP (1.5 g/kg day 1.0 g/kg day 3) 1. Do not conflate these protocols.