How to Order Terlipressin and Albumin for Hepatorenal Syndrome in a 50kg Patient
Start with terlipressin 1 mg IV bolus every 6 hours through a peripheral line plus albumin 50g IV on day 1, followed by 20-40g daily, without requiring ICU admission or central line placement in most cases. 1
Pre-Treatment Assessment and Contraindications
Before ordering, verify the following absolute contraindications:
- Serum creatinine >5 mg/dL (unlikely to benefit) 1
- Oxygen saturation <90% on room air or supplemental oxygen (FDA contraindication) 1, 2
- Active coronary, peripheral, or mesenteric ischemia 2
- Baseline electrocardiogram to screen for ischemic heart disease 2
Confirm HRS-AKI diagnosis by ensuring:
- Creatinine >1.5 mg/dL despite 2 days of diuretic withdrawal and volume expansion 1
- Diagnostic paracentesis performed to exclude spontaneous bacterial peritonitis 1, 3
- No nephrotoxic drug exposure 1
Exact Orders for a 50kg Patient
Day 1 Orders:
Terlipressin:
- Terlipressin 1 mg (1 vial) IV push undiluted every 6 hours (total 4 mg/day) 1, 2
- Administer through peripheral IV line—no central line required 1, 2
- No ICU monitoring required unless ACLF grade ≥3 1, 2
Albumin:
- Albumin 25% solution: 50g IV on day 1 (1 g/kg for 50kg patient, maximum 100g) 1, 2
- Infuse over 2-4 hours to avoid volume overload 1
Days 2-14 Orders:
Terlipressin:
- Continue terlipressin 1 mg IV push every 6 hours 1
- Check serum creatinine on day 3-4 1, 2
- If creatinine has NOT decreased by ≥25-30% from baseline by day 4: increase to 2 mg IV push every 6 hours (total 8 mg/day) 1
- If creatinine remains unchanged or increased despite dose escalation: discontinue treatment 4
Albumin:
- Albumin 25% solution: 20-40g IV daily 1, 2
- Reassess volume status after 1-2 days—consider reducing or stopping albumin if volume overloaded, but continue terlipressin 1, 4
Monitoring Orders
Vital signs every 2-4 hours including:
- Blood pressure (expect MAP increase of ~16 mmHg) 5
- Heart rate (expect decrease of ~10 beats/minute) 3, 5
- Oxygen saturation 1, 2
Laboratory monitoring:
Watch for ischemic complications (occur in 12% of patients): 1, 2
- Abdominal pain
- Chest pain
- Digital ischemia
- Arrhythmias
Watch for respiratory failure (occurs in 30% with ACLF grade 3): 1, 2
- Increased oxygen requirement
- Worsening dyspnea
Duration and Stopping Criteria
Continue treatment until ONE of the following:
- Serum creatinine ≤1.5 mg/dL on two consecutive measurements at least 2 hours apart, then continue for 24 hours after achieving this target 1, 4
- Maximum 14 days of therapy 1, 4
- Development of serious ischemic complications requiring permanent discontinuation 1
- Creatinine unchanged or increased on day 4 despite dose escalation to 2 mg every 6 hours 4
Critical Pitfalls to Avoid
Volume overload from excessive albumin: 1
- Albumin likely achieves its circulatory effect within 1-2 days 1
- After initial 1-2 days, reassess volume status daily using clinical exam or point-of-care ultrasound 1
- If anasarca or pulmonary edema develops, stop albumin but continue terlipressin 3
- Do not wait beyond day 4 to escalate dose if creatinine reduction is <25-30% 1, 2
- Higher baseline creatinine is associated with lower response rates—start treatment early 1
Inappropriate ICU admission: 1, 2
- Most patients (ACLF grade <3) do NOT require ICU monitoring 1, 2
- ICU admission only needed for ACLF grade 3 (≥3 organ failures) due to respiratory failure risk 1, 2
Continuing treatment despite non-response: 4
- If no creatinine improvement by day 4 despite maximum dose (2 mg every 6 hours), discontinue therapy 4
- Patients with creatinine >5 mg/dL have very low response rates 1
Alternative if Terlipressin Fails or is Contraindicated
Switch to norepinephrine 0.5 mg/hour continuous IV infusion (requires ICU admission and central line), titrate up to 3 mg/hour to achieve MAP increase >10 mmHg, plus albumin 20-40g daily. 1, 2, 3