What is the recommended dose and administration of albumin (human albumin) for a patient with hepatorenal syndrome?

Albumin Administration in Hepatorenal Syndrome

For hepatorenal syndrome, administer albumin at 1 g/kg body weight on day 1 (maximum 100 g) followed by 20-40 g/day in combination with vasoconstrictors (terlipressin or norepinephrine), continuing until complete response or for a maximum of 14 days. 1, 2

Initial Dosing Protocol

• Day 1: Give 1 g/kg of actual body weight intravenously, with a maximum dose not exceeding 100 g 1, 3
• Day 2 onwards: Continue with 20-40 g/day until serum creatinine falls below 1.5 mg/dL or for a maximum of 14-15 days 1, 3, 4
• Albumin should be administered as 20% or 25% solution intravenously 1

Critical Prerequisites Before Starting Albumin

Before initiating albumin therapy, you must first:

• Withdraw all diuretics for at least 2 consecutive days 1
• Perform volume expansion with albumin 1 g/kg for 2 consecutive days to exclude pre-renal AKI 1
• Rule out other causes: Ensure no shock, no nephrotoxic drugs (NSAIDs, aminoglycosides, contrast), no proteinuria >500 mg/day, no microhematuria >50 RBCs per high power field 1
• Only proceed with vasoconstrictor + albumin therapy if renal function does not improve after these initial 2 days of volume expansion 1

Combination with Vasoconstrictors

Albumin is never used alone for hepatorenal syndrome treatment—it must be combined with vasoconstrictors:

First-Line: Terlipressin + Albumin

• Terlipressin 0.5-1 mg IV every 4-6 hours, increased to maximum 2 mg every 4-6 hours if creatinine doesn't decrease by ≥25% after 3 days 3, 5
• This combination achieves 70% response rate versus only 29% with midodrine/octreotide 5
• Significantly more effective than albumin alone (43.5% vs 8.7% improvement) 6

Alternative: Norepinephrine + Albumin (requires ICU)

• Norepinephrine 0.5-3.0 mg/hour IV to increase mean arterial pressure by 10-15 mmHg 3, 7
• Comparable efficacy to terlipressin (83% success rate in reversing HRS) 7
• Requires central venous access and ICU monitoring 7

Third-Line: Midodrine + Octreotide + Albumin

• Midodrine 7.5-12.5 mg orally three times daily + Octreotide 100-200 μg subcutaneously three times daily 3
• Less effective than terlipressin (28.6% vs 70.4% response rate) and should only be used when terlipressin/norepinephrine unavailable 5

When to STOP Albumin

Discontinue albumin immediately if anasarca (severe peripheral edema) develops, as continued administration will worsen volume overload without benefit 2

• Continue vasoconstrictors even after stopping albumin 2
• The development of anasarca indicates poor prognosis and urgent need for transplant evaluation 2
• Albumin has no role in managing refractory ascites outside of large-volume paracentesis 2

Monitoring Response

• Check serum creatinine every 2-3 days 3
• Complete response: Creatinine ≤1.5 mg/dL on two occasions 3
• Partial response: Creatinine decrease ≥25% but still >1.5 mg/dL 8
• Monitor for cardiovascular complications (ischemia, pulmonary edema) which occur more frequently with vasoconstrictor therapy 6

Important Predictors of Response

• Lower baseline creatinine is the strongest independent predictor of treatment success 8, 4
• Baseline urine volume and absence of hyperkalemia predict better response 8
• Albumin co-administration dramatically improves response: 77% with terlipressin + albumin vs only 25% with terlipressin alone 4
• Absence of portal vein thrombosis associated with better outcomes 8

Common Pitfalls to Avoid

• Never use albumin alone—it requires vasoconstrictor combination for HRS treatment 6, 4
• Never use octreotide as monotherapy—it is ineffective without midodrine 3, 7
• Do not continue albumin in anasarca—this worsens volume overload 2
• Do not exceed 100 g albumin on day 1—higher doses associated with worse outcomes, possibly from fluid overload 1
• Do not delay transplant evaluation—pharmacological therapy is a bridge to transplantation, not definitive treatment 7