Albumin Content and Dosing for Hepatorenal Syndrome
A 20% albumin 50ml vial contains 10 grams of albumin, and a 50kg patient with hepatorenal syndrome requires 50 grams on day 1 (5 vials), followed by 20-40 grams daily (2-4 vials) thereafter. 1, 2
Calculation Breakdown
20% albumin solution contains:
For a 50kg patient with hepatorenal syndrome:
Day 1 Loading Dose
- Dose: 1 g/kg body weight (maximum 100g) 3, 1
- 50kg × 1 g/kg = 50 grams total
- Number of 50ml vials needed: 5 vials (50g ÷ 10g per vial) 2
- This loading dose should be administered within the first day, ideally before or concurrent with vasoconstrictor therapy 2
Day 2 and Beyond (Maintenance Dosing)
- Dose: 20-40 g/day 3, 1, 2
- Number of 50ml vials needed: 2-4 vials daily 1, 2
- Continue until complete response (serum creatinine ≤1.5 mg/dL) or maximum 14 days 1, 4
Critical Prerequisites Before Starting Albumin
Volume expansion protocol must be followed: 3, 1
- Withdraw all diuretics for at least 2 consecutive days 1
- Administer albumin 1 g/kg for 2 consecutive days to exclude pre-renal acute kidney injury 1
- Confirm serum creatinine remains >1.5 mg/dL despite this volume expansion 3
Albumin is never used alone - it must be combined with vasoconstrictors (terlipressin, norepinephrine, or midodrine/octreotide) 1
Important Monitoring Considerations
Watch for fluid overload complications: 3, 1
- Pulmonary edema occurred in 8% of patients receiving albumin with terlipressin in recent trials 2
- Doses exceeding 100g on day 1 are associated with worse outcomes, possibly due to fluid overload 3, 1
- Monitor for anasarca - if it develops, discontinue albumin but continue vasoconstrictors 4
Clinical monitoring parameters: 4, 2
- Check serum creatinine every 2-3 days to assess response 1, 4
- Monitor urine output, vital signs, and consider central venous pressure monitoring when available 2
- Complete response is defined as creatinine ≤1.5 mg/dL on two occasions 1, 4
Evidence Quality
The albumin dosing regimen of 1 g/kg on day 1 (maximum 100g) followed by 20-40 g/day is supported by Grade 1A evidence from multiple international guidelines 3, 1, 2. The 2021 Gut guidelines and 2025-2026 consensus recommendations consistently endorse this protocol 3, 1, 4. The FDA label for terlipressin confirms albumin administration at 1 g/kg on day 1 (maximum 100g) and 20-40 g/day thereafter in the CONFIRM trial 5.