What is the recommended dose of albumin for a patient with hepato-renal syndrome?

Albumin Dosing in Hepatorenal Syndrome

For hepatorenal syndrome-AKI (HRS-AKI), administer 1 g/kg IV albumin (maximum 100 g/day) for the first 2 consecutive days, followed by 20-40 g/day maintenance dosing throughout vasoconstrictor therapy. 1

Initial Loading Phase

• Give 1 g/kg IV albumin on day 1 and day 2 when HRS-AKI is diagnosed, with a maximum cap of 100 g per day 1, 2
• This loading dose serves dual purposes: it acts as a diagnostic challenge (confirming HRS-AKI if creatinine fails to improve despite volume expansion) and initiates therapeutic volume expansion 2
• Administer the loading dose before or concurrent with vasoconstrictor initiation (terlipressin, norepinephrine, or midodrine/octreotide) 1
• Use 20% or 25% albumin solution to minimize fluid volume in patients already at risk for volume overload 3, 2

Maintenance Dosing

• Continue with 20-40 g/day IV albumin after completing the 2-day loading phase 1, 2, 4
• Maintain this daily dose throughout the entire treatment course, typically extending until HRS reversal or for a maximum of 14 days 1, 4
• The combination of albumin with vasoconstrictors is essential—albumin alone is ineffective for HRS-AKI management 2

Critical Monitoring to Prevent Complications

• Monitor closely for pulmonary edema and respiratory failure, which occurred in 8% of patients receiving terlipressin with albumin in recent trials 1, 5
• Assess fluid status using urine output, vital signs, and when indicated, echocardiography or central venous pressure monitoring 1
• Excessive albumin administration may lead to respiratory failure, so careful volume assessment is mandatory 2
• Consider that death within 90 days due to respiratory disorders occurred in 11% of patients receiving terlipressin with albumin versus 2% with placebo in the CONFIRM trial 5

Evidence Quality and Rationale

The dosing regimen of 1 g/kg loading followed by 20-40 g/day maintenance is supported by Grade 1A evidence from multiple sources 1. This protocol was established in landmark trials showing that terlipressin plus albumin achieved HRS reversal in 32-43.5% of patients compared to 8.7-17% with albumin alone or placebo 4, 5. The albumin component provides volume expansion through oncotic effects while also delivering anti-inflammatory and other non-oncotic properties critical for HRS management 2.

Special Clinical Scenarios

When Performing Large Volume Paracentesis

• If draining >5L of ascites, administer 8 g albumin per liter of ascites removed after the procedure is completed 2
• Use 20% or 25% albumin solution 2, 3

When Spontaneous Bacterial Peritonitis (SBP) is Present

• Administer 1.5 g/kg within 6 hours of SBP diagnosis, followed by 1.0 g/kg on day 3 2
• This regimen is particularly important in patients with serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL 1
• Avoid doses exceeding 87.5 g (>4×100 mL of 20% albumin) as retrospective data suggests worse outcomes possibly due to fluid overload 2

Common Pitfalls to Avoid

• Do not use albumin as monotherapy for HRS-AKI—it must be combined with vasoconstrictors 2
• Do not delay treatment initiation—higher pretreatment serum creatinine is associated with treatment failure 2
• Do not ignore volume status—while adequate albumin is critical, excessive administration causes respiratory complications 2, 5
• If crystalloids must be substituted due to albumin unavailability, recognize that they are less effective than albumin for HRS-AKI treatment 2