What is the recommended albumin dosage for hepatorenal syndrome (HRS)?

From the Guidelines

For hepatorenal syndrome (HRS), albumin should be administered at a dose of 1 g/kg intravenously on day 1, followed by 20-40 g daily thereafter, in combination with vasoactive agents such as terlipressin, as recommended by the most recent guidelines 1.

Key Considerations

• The treatment should continue for the duration of vasoconstrictor treatment, which is generally until 24 hours following the return of the serum creatinine level to within ≤0.3 mg/dL of baseline for 2 consecutive days or for a total of 14 days of therapy 1.
• Albumin helps expand plasma volume, improve cardiac output, and reduce endothelial dysfunction in HRS, and it also has important non-oncotic properties including antioxidant effects and binding capacity for toxins and drugs.
• Patients should be monitored for signs of volume overload during administration, particularly those with cardiac dysfunction.
• The combination of albumin with vasoconstrictors is more effective than either treatment alone, as vasoconstrictors counteract splanchnic vasodilation while albumin improves effective circulating volume.

Supporting Evidence

• A recent study published in Clinical Gastroenterology and Hepatology in 2022 provides the best practice advice for the treatment of HRS-AKI, recommending albumin at a dose of 1 g/kg intravenously on day 1, followed by 20-40 g daily thereafter, in combination with vasoactive agents 1.
• Another study published in Hepatology in 2021 also supports the use of albumin in combination with vasoconstrictors for the treatment of HRS-AKI, although it recommends a slightly different dosing regimen 1.

Clinical Implications

• The treatment of HRS should be initiated promptly upon diagnosis to improve chances of renal recovery.
• The choice of vasoconstrictor agent may depend on institutional preferences and availability, with terlipressin being a commonly used option.
• Patients should be closely monitored for signs of treatment response and potential side effects, and the treatment regimen should be adjusted accordingly.

From the FDA Drug Label

All patients underwent fluid challenge with intravenous albumin (1 g/kg on the first day (maximum 100 g) and 20 g/day to 40 g/day thereafter as clinically indicated). Both treatment groups received albumin therapy during the study (median dose 50 g/day).

The recommended albumin dosage for hepatorenal syndrome is:

• 1 g/kg on the first day (maximum 100 g)
• 20 g/day to 40 g/day thereafter as clinically indicated with a median dose of 50 g/day 2

From the Research

Albumin Dosage for Hepatorenal Syndrome

• The dosage of albumin for hepatorenal syndrome is not explicitly stated in the provided studies, but it is mentioned that albumin is administered intravenously at a dose of 1 g/kg of body weight on day 1 and 20-40 g/day thereafter 3.
• In another study, albumin was administered at a dose of 1 g/kg of body weight on day 1, followed by 20-40 g/day, in combination with midodrine and octreotide 4.
• The use of albumin in combination with vasoconstrictor agents, such as terlipressin or midodrine and octreotide, has been shown to improve renal function and survival in patients with hepatorenal syndrome 5, 3, 6, 7.

Treatment Regimens

• Terlipressin plus albumin has been shown to be effective in improving renal function and short-term survival in patients with hepatorenal syndrome, with a response rate of 35-45% 5.
• Midodrine and octreotide plus albumin have also been used as an alternative treatment for hepatorenal syndrome, with promising results 3, 4, 7.
• The combination of octreotide, midodrine, and albumin has been shown to improve survival and renal function in patients with type 1 and type 2 hepatorenal syndrome 7.