Albumin Regimen for Acute Decompensated Liver Cirrhosis

Introduction to Albumin Therapy

The American Association for the Study of Liver Diseases (AASLD) recommends administering 1 g/kg of IV albumin (maximum 100 g) on day 1, followed by 20-40 g/day on subsequent days when treating with vasoconstrictors for hepatorenal syndrome in patients with acute decompensated cirrhosis and acute kidney injury (AKI) 1

For acute kidney injury (AKI) without specific complications, the recommended dosing is 1 g/kg of body weight (maximum 100 g/day) as a volume challenge after withdrawing diuretics and treating precipitating factors, with ongoing therapy of 20-40 g/day in combination with vasoconstrictors if hepatorenal syndrome (HRS-AKI) Stage 2 or greater is diagnosed 1
The optimal duration of albumin beyond the initial 48-hour period remains unclear, but treatment should continue until complete response (improved kidney function) or for a maximum of 14 days 2

For spontaneous bacterial peritonitis (SBP), the established regimen is 1.5 g/kg within 6 hours of SBP diagnosis, and 1.0 g/kg on day 3, which is particularly beneficial for patients with elevated serum bilirubin or creatinine, reducing AKI risk and mortality 3, 4
For large-volume paracentesis, administer 6-8 g of albumin per liter of ascites removed, given after the procedure is completed, applying only when more than 5 liters are removed 7, 3

The maximum safe dose should not exceed 87.5-100 g in the initial loading period, as doses above this threshold are associated with worse outcomes due to fluid overload 8
Use 20% or 25% albumin solution, and for continuous therapy with vasoconstrictors, the mean dose is 20-40 g/day, with monitoring of central venous pressure to prevent circulatory overload 5, 9, 2

Albumin should not be administered in scenarios of uncomplicated ascites without AKI, SBP, or large-volume paracentesis, infections other than SBP, routine volume resuscitation in critically ill cirrhotic patients, or treatment of hypoalbuminemia alone 3, 4, 5, 9
The evidence supporting albumin is strongest for HRS-AKI Stage 2 or greater, SBP with elevated creatinine or bilirubin, and large-volume paracentesis more than 5 liters 1, 3, 6
If using albumin with vasoconstrictors for HRS-AKI, screen for cardiovascular disease before starting terlipressin, as cardiovascular complications can occur in up to 45% of patients 2