with albumin administration ( recommended dose : 1g / kg of body weight per day , up to a maximum of 100g / day ), reducing further fluid loss with discontinuation of diuretics , and avoiding nephrotoxic drugs especially radiocontrast agents and non-steroidal anti-inflammatory drugs . The presence of renal structural damage or urinary tract obstruction should be excluded by ultrasonography . However , distinguishing between HRS and ATN is not always easy , even with the assessment of urinary biomarkers of renal
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tubular damage . Once the diagnosis is established , the most effective treatment of HRS includes the administration of vasoconstrictors ( mostly terlipressin ) in association with intravenous albumin ( 20 – 40g / day for up to two weeks ). 11 Rates of response to this treatment range from 64 % to 76 %, with a complete response ranging from 46 % to 56 %. Survival is only improved in the short term , but this is not surprising given that patients with HRS usually have very advanced cirrhosis . Interestingly , the association of terlipressin plus albumin is more effective than terlipressin alone . 16 The beneficial effect of vasoconstrictors along with albumin supplementation in patients with cirrhosis and HRS-AKI has been shown in metaanalyses . 17 , 18 The favorable effects of albumin are due to an improvement in volemia , which not only results from plasma volume expansion , but is also
because of improvements in hemodynamics such as stroke work and peripheral vascular resistance , which are absent with synthetic colloids such as hydroxyethyl starch ( HES ). 19 These results suggest an effect of albumin on endothelial function , as plasma Von Willebrand-related antigen only decreased in patients treated with albumin and serum nitrates and nitrites only increased in patients treated with HES . Furthermore , albumin infusion ( but not HES ) was also able to restore an impaired cardiac contractility in an experimental rodent model of cirrhosis . 20
Prevention of paracentesis-induced circulatory dysfunction Large volume paracentesis ( LVP ) is the current treatment of choice for patients with tense and refractory ascites . 21 The removal of large volumes of ascitic fluid can be followed by paracentesisinduced circulatory dysfunction ( PICD ), defined as a significant increase (> 50 %) in plasma renin activity six days after LVP . 21 In several randomized trials , albumin was able to lower the incidence rate of PICD in comparison to other colloid volume expanders . 21
On the basis of such evidence , both American and European guidelines recommend the administration of 8g albumin / l of tapped ascites , when more than 5l of ascites are removed . 11 , 12 Due to high cost and potential low availability of albumin ,
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