What is the role of albumin in liver cirrhosis?

From the Guidelines

Albumin is recommended for specific indications in patients with cirrhosis, particularly for large-volume paracentesis, hepatorenal syndrome, and spontaneous bacterial peritonitis (SBP), as it has been shown to improve outcomes in these conditions, including reducing the risk of renal impairment and mortality 1.

Indications for Albumin Use

• Large-volume paracentesis: administer intravenous albumin at a dose of 6-8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction and reduce the risk of renal impairment.
• Hepatorenal syndrome: use albumin in combination with vasoconstrictors, with a typical regimen of albumin 1 g/kg on day 1, followed by 20-40 g daily for up to 2 weeks, alongside terlipressin or norepinephrine.
• Spontaneous bacterial peritonitis (SBP): administer albumin at a dose of 1.5 g/kg on day 1, followed by 1 g/kg on day 3, to prevent the development of renal dysfunction and decrease mortality.

Rationale for Albumin Use

The use of albumin in cirrhosis is based on its ability to improve effective circulating volume, reduce systemic inflammation, and enhance the binding and transport of various molecules, which helps counteract the pathophysiological changes seen in advanced liver disease, including splanchnic vasodilation and impaired cardiac function 1.

Important Considerations

• Routine use of albumin for all cirrhotic patients is not recommended, and its use should be targeted to specific clinical scenarios where evidence supports its benefit.
• The dose of albumin should be carefully considered, as excessive doses can lead to fluid overload, particularly in patients with SBP.
• Albumin should not be used in patients with cirrhosis and uncomplicated ascites, as standard therapy for cirrhotic ascites is sodium restriction plus diuretics (spironolactone with or without furosemide) 1.

From the Research

Role of Albumin in Liver Cirrhosis

• Albumin has been used primarily as a plasma expander, leading to an increase in the circulating blood volume 2
• Current indications for albumin therapy in cirrhotic patients include:
  • Prevention of circulatory dysfunction after large-volume paracentesis
  • Prevention of hepatorenal syndrome (HRS) in patients with spontaneous bacterial peritonitis (SBP)
  • Management of HRS in combination with vasoconstrictors 2, 3
• Albumin also has non-oncotic properties, including:
  • Antioxidant
  • Radical scavenger
  • Immune modulator 2
• Long-term albumin administration in patients with decompensated cirrhosis may be useful in preventing associated complications, such as acute-on-chronic liver failure and infections 2
• Albumin therapy has been shown to improve survival, prevent complications, simplify ascites management, and lower hospitalization rates in patients with cirrhosis and ascites 2, 4

Controversies and Debates

• The optimal dosage and administration intervals for albumin therapy have not yet been finally defined 2, 5
• The use of albumin in non-SBP infections and as long-term therapy is promising, but requires further confirmation by studies 2, 5
• The indication and patient selection for albumin use are crucial and not always intuitive, with some studies showing negative, controversial, or inconclusive results 5

Clinical Applications

• Albumin infusion is recommended after large-volume paracentesis, at diagnosis of spontaneous bacterial peritonitis, in acute kidney injury, and in hepatorenal syndrome 5, 3
• Albumin has been shown to be beneficial in treating patients with decompensated cirrhosis, including those with hyponatremia and diuretic-resistant ascites 4