Patients with cirrhosis, AKI may require 48 h to respond to albumin therapy

Many patients with cirrhosis and acute kidney injury (AKI) need 2 days to show response to albumin treatment, a study has found. Therefore, reducing the duration of albumin therapy may result in overtreatment with terlipressin.

“[T]he key finding of our current study is that about one-quarter of patients (depending on the definition used) who respond to albumin will have this response in the second 24 h of albumin treatment,” the researchers said.

Analysis was carried out using data from 127 prospectively recruited patients with cirrhosis and AKI from two German centres. Three response definitions after 24 and 48 h were examined: (1) serum creatinine (SCr) decrease >0.3 mg/dl, (2) SCr decrease >25 percent, and (3) SCr decrease in at least one AKI stage. Follow-up was delayed until liver transplantation, death, or haemodialysis.

Of the patients, 30 percent to 54 percent responded to albumin treatment depending on the definition. The response rates were balanced across AKI stages. A substantial number of participants did not respond within the first 24 h but did so at 48 h. [J Hepatol 2025;83:682-691]

Additional responses to albumin treatment during the second 48 h were 28 percent for definition 1, 22 percent for definition 2, and 18 percent for definition 3. Response based on definition 3 correlated with higher rates of haemodialysis- and transplantation free survival.

“The findings of our current study argue strongly against a universal shortening of the duration of albumin treatment for each patient with AKI before initiating combination therapy with terlipressin since up to 30 percent of responders will do so between 24 and 48 h,” the researchers said.

“Another important finding is that only response definition 3 was associated with a better prognosis, [while] a reduction in SCr of 0.3 mg/dl or by 25 percent was not associated with survival,” they added.

Standard definition

There is currently no standard definition of response to albumin treatment. Furthermore, albumin has well-known volume expansion effects that may cause a simple dilution of SCr, which depended on the volume used and the body weight of the patient. [Nephrol Dial Transpl Off Publ Eur Dial Transpl Assoc - Eur Ren Assoc 2023;38:1603-1612; Intensive Care Med 2015;41:160-161]

According to the European Association for the Study of the Liver (EASL) guidelines and International Club of Ascites criteria, a response must be characterized by a full response (SCr decreasing back to within 0.3 mg/dl of the baseline value) or partial response (defined as an SCr decrease in at least one AKI stage without reaching <0.3 mg/dl of baseline CRs). [J Hepatol 2019;71:811-822; J Hepatol 2018;69:406-460]

“According to these guidelines, any response (both partial and full) would be considered a response to albumin,” the researchers said.

“The American Association for the Study of Liver Diseases guideline does not provide any guidance in this sense,” they added. [Hepatology 2021;74:1014-1048]

“Expert opinions suggest that the resolution of AKI (full response according to EASL-proposed definition) should be considered as response to albumin,” the researchers said. [Nat Rev Dis Primer 2018;4:23]