Albumin Administration in Hepatic Encephalopathy

Introduction to Albumin Use

The American Thoracic Society recommends albumin administration in combination with standard therapy to improve resolution of encephalopathy and reduce mortality in patients with hepatic encephalopathy 1

A 2021 systematic review identified two randomized controlled trials showing that albumin administration resulted in a reduction in hepatic encephalopathy and mortality in patients with hepatic encephalopathy (RR 0.60; 95% CI 0.38-0.95) and (RR 0.54; 95% CI 0.33-0.90) 1
The first open-label trial showed that albumin plus lactulose achieved complete resolution of hepatic encephalopathy in 75% of patients versus 53% with lactulose alone in patients with hepatic encephalopathy (P=0.03) 1
The same trial demonstrated reduced mortality at day 10 in the albumin-lactulose group compared to lactulose alone in patients with hepatic encephalopathy (18% vs 32%, P=0.04) 1
A second masked RCT using albumin showed improved 90-day mortality and transplant-free survival compared to normal saline in patients with hepatic encephalopathy (23% vs 47%) (P=0.02) 1

For acute hepatic encephalopathy: 1.5 g/kg on day 1 followed by 1.0 g/kg on day 3 is recommended by the American College of Chest Physicians 1, 2
For acute hepatic encephalopathy: 1.5 g/kg/day for up to 10 days in combination with lactulose is an alternative regimen recommended by the American College of Chest Physicians 1

The American College of Chest Physicians notes that potential adverse effects of albumin administration include fluid overload and pulmonary edema, particularly in patients with compromised cardiac or pulmonary function 2
The American College of Chest Physicians also notes that patients with cirrhosis are at higher risk for adverse effects due to increased capillary permeability, and that more severe or life-threatening serious adverse events have been reported in albumin-treated patients, primarily pulmonary edema 2

The American College of Radiology recommends albumin for prevention of circulatory dysfunction after large-volume paracentesis (>5L) in cirrhotic patients 4
The European Association for the Study of the Liver recommends albumin for prevention of hepatorenal syndrome in patients with spontaneous bacterial peritonitis (1.5 g/kg at diagnosis and 1g/kg on day 3) 6