Background and aims: Guidelines recommended volume expansion with albumin for 48 hours for patients with cirrhosis and acute kidney injury (AKI) to correct hypovolemia and rule out prerenal AKI. A recent update in the Acute Disease Quality Initiative (ADQI)-International Club of Ascites (ICA) consensus guidelines suggested shortening this duration to 24 hours, primarily based on expert opinion. This study aimed to evaluate the response rates to albumin treatment after 24 and 48 hours and to compare and assess the prognostic significance of three different definitions of response to albumin therapy.

Methods: Data from 127 prospectively recruited patients with cirrhosis and AKI from two German centers were analyzed. We examined three response definitions after 24 and 48 hours: (1) serum creatinine (SCr) decrease > 0.3 mg/dl, (2) SCr decrease >25 %, and (3) SCr decrease in at least one AKI stage. Follow-up was prolonged until liver transplantation, death or hemodialysis (HD).

Results: Overall, 30-54 % of the patients responded to albumin treatment depending on the definition, and response rates were balanced across AKI stages. Notably, a relevant number of patients who responded at 48 hours did not respond within the first 24 hours. Additional response to albumin during the second 24 hours were 38 %, 24 %, and 25 % (definitions 1, 2, and 3, respectively). Response according to definition 3 was associated with a better HD- and transplantation-free survival.

Conclusion: A substantial proportion of patients requires 48 hours to respond to albumin treatment. Shortening time of albumin therapy may lead to overtreatment with terlipressin.

Impact and implications: This study provides valuable insights into the optimal duration of albumin treatment for patients with cirrhosis and acute kidney injury (AKI), challenging the recent recommendation of shortening the treatment period with albumin. Furthermore, the optimal definition for response to albumin (reduction of at least one AKI stage) has been assessed. The results of this study are highly clinically relevant since shortening albumin therapy may lead to overtreatment with terlipressin, and evidence to support the choice of the definition of response to albumin was lacking. Clinicians can use these findings to predict treatment outcomes better, avoid fluid overload, and improve patient prognosis while also considering the potential risks of early intervention with terlipressin.

Keywords: ICA; KDIGO; acute kidney injury; albumin; ascites; cirrhosis; hepatorenal syndrome; portal hypertension; terlipressin; volume therapy.

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