What is the recommended dose of albumin for a patient with decompensated cirrhosis?

Albumin Dosing in Decompensated Cirrhosis

For decompensated cirrhosis patients, albumin dosing depends critically on the specific clinical scenario: administer 1 g/kg (maximum 100 g) on day 1 followed by 1 g/kg on day 3 for spontaneous bacterial peritonitis; 1 g/kg (maximum 100 g) on day 1 followed by 20-40 g/day for hepatorenal syndrome-AKI when combined with vasoconstrictors; 6-8 g per liter of ascites removed for large-volume paracentesis >5L; and 1 g/kg (maximum 100 g) for 2 consecutive days as a volume challenge for AKI stage >1A without obvious cause. 1

Clinical Context-Specific Dosing Algorithm

For Spontaneous Bacterial Peritonitis (SBP)

• Administer 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 2, 1
• This regimen reduces type 1 hepatorenal syndrome incidence from 30% to 10% and mortality from 29% to 10% compared to antibiotics alone 2
• Particularly beneficial when baseline serum bilirubin ≥68 µmol/L (4 mg/dl) OR creatinine ≥88 µmol/L (1 mg/dl) 2
• Patients with bilirubin <68 µmol/L AND creatinine <88 µmol/L have very low HRS risk (0-7%), making albumin potentially unnecessary 2

For Hepatorenal Syndrome-AKI (HRS-AKI)

• Initial loading: 1 g/kg body weight (maximum 100 g) on day 1 1
• Maintenance: 20-40 g/day intravenously in combination with vasoconstrictors (typically terlipressin) 2, 1
• Continue treatment until complete response (serum creatinine <1.5 mg/dl) or for maximum 14 days 2, 1
• Start vasoconstrictors promptly—higher baseline creatinine correlates with treatment failure 3
• Screen for cardiovascular disease before initiating terlipressin, as cardiovascular complications occur in up to 45% of patients 1

For Acute Kidney Injury (AKI) Without Specific Cause

• When AKI stage >1A occurs without obvious precipitating factors, give 1 g/kg (maximum 100 g) for 2 consecutive days after withdrawing diuretics 2, 1
• If HRS-AKI Stage 2 or greater is subsequently diagnosed, transition to 20-40 g/day with vasoconstrictors 1
• The optimal dose for survival benefit in ARF is 87.5 g, with doses above 100 g associated with worse outcomes due to fluid overload 4

For Large-Volume Paracentesis

• Administer 6-8 g of albumin per liter of ascites removed 1, 5
• Only indicated when >5 liters are removed 1, 5
• Give albumin after the paracentesis procedure is completed 1

For Sepsis-Induced Hypotension

• Use 5% albumin solution over normal saline 5
• A 2024 RCT demonstrated higher 1-week survival with albumin (43.5% vs 38.3%, p=0.03) 5, 3

Critical Dosing Thresholds and Safety

Maximum Safe Dose

• Do not exceed 87.5-100 g in the initial loading period 4
• Doses above this threshold are associated with increased mortality and complications from fluid overload 4
• Use 20% or 25% albumin solution for all indications 1

Monitoring for Volume Overload

• Monitor central venous pressure to prevent circulatory overload, though CVP is inaccurate for assessing cardiac output in cirrhosis 2
• Use transthoracic echocardiography at bedside to evaluate volume status and cardiac function 3
• Watch for respiratory distress or declining oxygen saturation during administration 5
• Immediately discontinue if pulmonary edema develops 5
• Length of stay and critical care requirements increase in a dose-dependent manner with albumin 4

Common Pitfalls to Avoid

Do NOT Use Albumin For:

• Uncomplicated ascites without AKI, SBP, or large-volume paracentesis 1
• Routine volume resuscitation in critically ill cirrhotic patients—use balanced crystalloids (lactated Ringer's) instead 1, 5
• Treatment of hypoalbuminemia alone—correcting low albumin levels without specific complications does not improve outcomes 5
• Infections other than SBP 1
• Small-volume paracentesis (≤5 liters) 1

Key Clinical Considerations

• Albumin alone is ineffective for HRS-AKI—must be combined with vasoconstrictors 3
• Beta-blockers should be stopped when AKI develops, though data are controversial 2
• Discontinue all diuretics immediately when AKI is diagnosed 2
• Each 1 mg/dL reduction in creatinine with treatment reduces mortality risk by 27% 3
• The ATTIRE trial showed maintaining elevated albumin levels long-term increased pulmonary edema rates without improving composite outcomes 5, 3

Practical Administration Details

Preparation and Delivery

• Administer intravenously using 20% or 25% albumin solution 1
• For continuous therapy with vasoconstrictors, mean dose is 20-40 g/day 2, 1
• Terlipressin can be given by continuous IV infusion at 2 mg/day (lower adverse effects) or IV boluses 0.5-1 mg every 4-6 h, increased to maximum 2 mg every 4-6 h if creatinine reduction <25% 2

Response Assessment

• Complete response: serum creatinine below 1.5 mg/dl 2
• Partial response: decrease of creatinine ≥50% with final value still >1.5 mg/dl 2
• Response rates to terlipressin plus albumin range from 64-76%, with complete response in 46-56% 2