From the Guidelines
Low albumin levels in patients with cirrhosis are primarily managed with albumin infusions, and the use of albumin is recommended in specific situations such as spontaneous bacterial peritonitis (SBP) and large-volume paracentesis. The management of low albumin levels in cirrhosis patients involves understanding the underlying causes and addressing them appropriately. In patients with cirrhosis, low albumin levels can be due to various factors including decreased synthesis, increased catabolism, and loss of albumin through ascites or gastrointestinal bleeding.
Key Considerations
- The use of albumin in patients with SBP has been shown to reduce the risk of renal impairment and mortality, as evidenced by a multi-center RCT including 105 patients with SBP, where those who received antibiotics accompanied by IV albumin had a significantly lower rate of AKI (10% vs 33%) and death (10% vs 29%) compared with those who received antibiotics only 1.
- In patients with ascites undergoing large-volume paracentesis, albumin should be administered at a dose of 6–8 g/L regardless of the amount of ascites removed, as recommended in the aga clinical practice update on the use of vasoactive drugs and intravenous albumin in cirrhosis 1.
- Albumin is not advised in infections other than SBP, unless associated with AKI, as three RCTs and a meta-analysis comparing albumin with no albumin in patients with cirrhosis and infections other than SBP found that albumin does not reduce the risk of AKI or mortality and was associated with more pulmonary edema 1.
Management Strategies
- For patients with SBP, albumin at 1.5 g/kg on diagnosis day and 1 g/kg on day 3 reduces the risk of renal impairment and mortality 1.
- In patients with cirrhosis and large-volume paracentesis, 6-8 g of albumin should be administered per liter of ascitic fluid removed to prevent circulatory dysfunction 1.
- Addressing underlying liver disease through alcohol abstinence, viral hepatitis treatment, or weight loss in fatty liver disease is essential for long-term management.
- Nutritional support with adequate protein intake (1.2-1.5 g/kg/day) and sodium restriction (<2 g/day) should accompany albumin therapy. The use of albumin in patients with cirrhosis should be guided by the specific clinical scenario and the presence of complications such as SBP or large-volume paracentesis, as supported by the evidence from the aga clinical practice update on the use of vasoactive drugs and intravenous albumin in cirrhosis 1.
From the Research
Low Albumin Levels in Cirrhosis
- Low albumin levels are commonly observed in patients with cirrhosis due to the liver's reduced ability to synthesize albumin 2, 3, 4.
- The liver is the exclusive site of albumin synthesis, and liver disease can lead to decreased albumin production 2.
- In advanced cirrhosis, the quality of albumin is also decreased due to high oxidative stress and a proinflammatory state 2.
Management of Low Albumin Levels
- Albumin infusion is recommended in certain situations, such as after large-volume paracentesis, at diagnosis of spontaneous bacterial peritonitis, in acute kidney injury, and in hepatorenal syndrome 2, 3, 5.
- The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics 6.
- 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 3, 4.
- However, the optimal dosage and administration intervals for albumin therapy have not yet been finally defined, and the indication and patient selection are crucial 2, 3.
Benefits and Risks of Albumin Therapy
- Albumin therapy has been shown to improve outcomes in patients with cirrhosis, including reducing mortality and hospitalizations 3, 5.
- Albumin has both oncotic and non-oncotic properties, which contribute to its beneficial effects in patients with cirrhosis 3, 4, 5.
- However, albumin therapy is not without risks, including allergic and transfusion reactions, volume overload, antibody formation, and coagulation derangements 4.