Effect of intravenous albumin infusion on plasma renin activity in children with decompensated cirrhosis

Background and Aim: Plasma renin activity(PRA) represents the activation of vasoconstrictor system in response to effective arterial hypovolemia that occurs in decompensated cirrhosis(DC). Albumin infusion is the standard of care in the context of spontaneous bacterial peritonitis(SBP), acute kidney injury(AKI), sepsis and to prevent post-paracentesis circulatory dysfunction. We did this study to assess the role of albumin infusion as a routine care in children with DC. Objective was to study the change and sustainable reduction of PRA(<2SD for age) by day 28 following albumin infusion. Methods: From March 2020 to November 2021, all cirrhotic children with decompensation and serum albumin<2.8g/dL were enrolled. Those with high PRA (>2SD above age-appropriate mean) were infused with 20% human albumin solution at 1g/kg/day (maximum 20g/day) for 72 hours and PRA levels were repeated on day 28. Results: Seventy-five (89.3%) of episodes of decompensation in cirrhotic children had high baseline PRA. The median change in PRA in DC children from baseline to day 28 was 7.85 (5.23, 29.60) to 8.45 (4.35, 20.10) ng/ml/hour which was not significant. Albumin infusion in the DC children with high PRA led to sustainable reduction of PRA in 8 (19.1%) children on day 28. No life-threatening serious event was reported related to albumin infusion. Baseline PRA positively correlated to liver dysfunction severity scores. By day 28, 25% children had poor outcome (Liver transplantation-2, death-19). By day 90, additional 11 children had poor outcome (Liver transplantation-4, death-7). Baseline PRA level did not independently predict poor outcome on multivariate analysis; PELD and pediatricCLIF-SOFA did. Conclusions: 89% of the decompensation episodes in children had high PRA at presentation. Albumin infusion does not lead to sustainable reduction in PRA at Day 28. Baseline PRA value, although positively correlated with severity of liver dysfunction, but is not independently associated with poor outcome.