From the Guidelines
Albumin should be administered at a dose of 1 g/kg body weight (maximum 100 g) for 48 hours, followed by 20-40 g/day, in patients with hepatorenal syndrome (HRS) who fulfill the diagnostic criteria for Stage 2 or greater HRS-AKI and do not have contraindications, as recommended by the most recent guidelines 1. The treatment of HRS involves the use of albumin to expand plasma volume and improve renal perfusion, in combination with vasoconstrictors such as terlipressin or norepinephrine.
- The initial dose of albumin is typically 1 g/kg body weight (maximum 100 g) for 48 hours, as stated in the AASLD practice guidance on acute-on-chronic liver failure and the management of critically ill patients with cirrhosis 1.
- After the initial 48 hours, the dose of albumin can be reduced to 20-40 g/day, as recommended by the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1.
- The treatment duration typically ranges from 5-14 days, continuing until serum creatinine decreases to below 1.5 mg/dL or at least 50% from baseline.
- Albumin works by increasing effective arterial blood volume, counteracting the splanchnic vasodilation that contributes to HRS pathophysiology, and also has anti-inflammatory and antioxidant properties that may provide additional benefits.
- Continuous monitoring of fluid status is essential during albumin administration to prevent volume overload, particularly in patients with pulmonary edema or severe hyponatremia.
- Treatment should be initiated promptly upon diagnosis as earlier intervention is associated with better outcomes, as stated in the AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis 1.
From the Research
Albumin Dose in Treatment of Hepatorenal Syndrome
- The dose of albumin used in the treatment of hepatorenal syndrome (HRS) varies across studies, but a common approach is to administer 1 g/kg of body weight on day 1, followed by 20-40 g/day thereafter 2.
- In one study, albumin was given to increase and/or maintain central venous pressure (CVP) above 3 cm H(2)O, with the need for albumin varying from patient to patient (extremes 40-600 g) and in the same patient from day to day 3.
- 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 HRS 4, 2, 5.
- The optimal dose and duration of albumin therapy in HRS have not been established, and further studies are needed to determine the most effective treatment strategy 4, 6.
Key Findings
- Terlipressin plus albumin has been shown to improve renal function in almost 35-45% of patients with AKI-HRS, as well as to improve short-term survival in these patients 4.
- Midodrine and octreotide plus albumin have also been used in the treatment of AKI-HRS, with promising results, but terlipressin plus albumin is significantly more effective in improving renal function 2.
- The response to treatment with albumin and vasoconstrictor agents is associated with better survival, and age, bilirubin, and creatinine increase after diagnostic volume expansion are independent predictors of death 5.