Volume expansion in the treatment of AKI HRS
How is volume expansion used in the treatment of AKI HRS?
Hypoalbuminemia is common in cirrhosis secondary to reduced synthesis, dilution from plasma volume expansion, and increased transcapillary escape into extravascular space.
In AKI-HRS, albumin infusions suppress sympathetic activity; specifically, it causes a decrease in plasma norepinephrine, reversing one of the primary abnormalities of cirrhotic pathophysiology.
Albumin alone has been shown to be ineffective in the treatment of AKI-HRS. The use of albumin plus vasoconstrictor was superior in lowering serum creatinine and reversing AKI-HRS when compared to albumin alone or vasoconstrictor alone.
However, there was no change in overall patient survival.
A recent meta-analysis showed that within the group of patients who received vasoconstrictor plus albumin, a higher cumulative dose of albumin was associated with a significantly improved 6-month survival.
In AKI-HRS, albumin should be given with vasoconstrictors at the dose of 1 g/kg on day 1 followed by 20 to 40 g/day until vasoconstrictors are withdrawn. Where possible, the albumin dose should be titrated according to the level of the central venous pressure of up to 10 cm of water.
Alternatively, albumin should be reduced or stopped in the presence of intravascular volume overload and/or pulmonary edema.
