Albumin in the Management of Hepatorenal Syndrome-Acute Kidney Injury: Is There Ever Too Much?

BACKGROUND: Concerns about albumin causing respiratory failure in patients with hepatorenal syndrome-acute kidney injury (HRS-AKI) have caused unease with excess albumin use in these patients. AIM: To assess the outcomes of patients with HRS-AKI who received varying daily albumin doses. METHODS: Retrospective study of inpatients with HRS-AKI between Jan 2020 and Apr 2023 collected clinical and laboratory data, AKI treatment, and hospital course with 6-month follow-up. 3 groups of patients such as no albumin, standard albumin (≤ 50 g/day), and high albumin (> 50 g/day) were compared. RESULTS: 159 AKI episodes were diagnosed in 149 patients (age 60 ± 11 years; male: 63%; MELD-Na: 29 ± 7). 16 AKI episodes received no albumin. Standard and high albumin patients had higher MELD score (p = 0.007) and higher Child-Pugh score (p = 0.057) compared to no albumin group. Standard albumin patients received 40 ± 10 g/day for 6.3 ± 6.5 days, versus 66 ± 14 g/day for 8.5 ± 6.7 days (p < 0.001 and p = 0.055, respectively) in high albumin group. 44 of 54 AKI episodes in high albumin patients had infection as an AKI precipitant (p < 0.001), 67% had stage 3 AKI (p = 0.002 vs. the other 2 groups) with peak creatinine at 403 ± 173 µmol/L, associated with higher rate of AKI progression (p = 0.01), with similar duration of hospital stay compared to the other 2 groups. Respiratory failure occurred in 2 patients in each albumin group related to pneumonia and aspiration. Survival at 6 months was not significantly reduced in the albumin groups (p = 0.141). CONCLUSION: Patients with severe liver dysfunction with HRS-AKI triggered by infection receiving more than recommended albumin dose did not have a more adverse outcome compared to standard albumin dose.