From the Guidelines
Albumin is indicated for specific conditions in patients with cirrhosis, including large-volume paracentesis, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and severe hypoalbuminemia with complications such as refractory ascites. The use of albumin in these conditions is supported by recent guidelines and studies, including the 2024 AASLD practice guidance on acute-on-chronic liver failure and the management of critically ill patients with cirrhosis 1.
Indications for Albumin Use
- Large-volume paracentesis: administer albumin at a dose of 6-8 g per liter of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction
- Spontaneous bacterial peritonitis (SBP): give albumin at 1.5 g/kg on day 1 and 1 g/kg on day 3 to reduce the risk of renal impairment and improve survival, as recommended by the 2021 guidelines on the management of ascites in cirrhosis 1
- Hepatorenal syndrome (HRS): use albumin in combination with vasoconstrictors like terlipressin, norepinephrine, or midodrine plus octreotide, typically at 20-40 g/day
- Severe hypoalbuminemia with complications such as refractory ascites: consider long-term albumin therapy at 20-40 g twice weekly
Important Considerations
- Monitor for volume overload, particularly in patients with cardiac dysfunction, as this is a potential complication of albumin administration
- Be aware of the potential adverse events related to albumin use, including fluid overload, pulmonary edema, and hypotension/tachycardia, as reported in the 2024 AGA clinical practice update on the use of vasoactive drugs and intravenous albumin in cirrhosis 1
- The use of albumin in patients with cirrhosis and infections other than SBP is not recommended, unless associated with acute kidney injury (AKI), as stated in the 2024 guideline from the International Collaboration for Transfusion Medicine Guidelines 1
Key Takeaways
- Albumin has a specific role in the management of patients with cirrhosis, particularly in preventing post-paracentesis circulatory dysfunction and reducing the risk of renal impairment and mortality in SBP
- The dose and duration of albumin therapy should be individualized based on the patient's condition and response to treatment
- Regular monitoring of the patient's volume status, renal function, and overall clinical condition is essential to minimize the risk of adverse events associated with albumin use.
From the Research
Indications for Albumin Use in Cirrhosis
The use of albumin in patients with cirrhosis is supported by various studies for specific indications. These include:
- Prevention of paracentesis-induced circulatory dysfunction 2
- Prevention of renal dysfunction induced by spontaneous bacterial peritonitis 3
- Diagnosis and treatment of acute kidney injury and hepatorenal syndrome 3
- Treatment of hepatorenal syndrome in association with vasoconstrictors 4
- Reduction of mortality and incidence of complications in patients with decompensated cirrhosis 5, 3
- Improvement of survival in cirrhotic patients with spontaneous bacterial peritonitis (SBP) and hepatic encephalopathy (HE) 6
Specific Patient Populations
Albumin use is particularly beneficial in certain patient populations, including:
- Patients with decompensated cirrhosis, where long-term albumin administration has been shown to reduce mortality and incidence of complications 5, 3
- Patients undergoing paracentesis, where albumin use reduces the risk of circulatory dysfunction 2
- Patients with cirrhosis and infection, where albumin use reduces mortality and renal impairment 2
Clinical Recommendations
Clinical recommendations for the use of human albumin in patients with cirrhosis have been produced by expert panels, including the Italian Association for the Study of the Liver (AISF) and the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) 4. These recommendations aim to implement appropriate prescription of human albumin and avoid its futile use.