From the Guidelines
Treating high direct bilirubin requires addressing the underlying cause rather than using albumin, as albumin does not address the fundamental issue of impaired bile excretion. The most recent and highest quality study, 1, published in 2021, provides guidelines on the management of ascites in cirrhosis and highlights the importance of treating the underlying cause of hyperbilirubinemia.
Causes and Treatment of Hyperbilirubinemia
The causes of hyperbilirubinemia can be varied, including:
- Cholestatic conditions, which may be treated with ursodeoxycholic acid (10-15 mg/kg/day)
- Infectious causes, which may be treated with antibiotics
- Hepatotoxic medications, which should be discontinued
- Biliary obstruction, which may require interventions like endoscopic retrograde cholangiopancreatography (ERCP) or surgery to restore bile flow
- Genetic conditions like Dubin-Johnson syndrome, which may require supportive care as the mainstay of treatment
Role of Albumin
Albumin is not an effective treatment for elevated direct (conjugated) bilirubin, as it does not address the fundamental issue of impaired bile excretion. However, albumin may be used in certain situations, such as in patients with spontaneous bacterial peritonitis (SBP) to prevent the development of renal dysfunction and decrease mortality, as shown in 1.
Supportive Measures
Supportive measures, including maintaining hydration and nutrition, are crucial while the underlying condition is being treated. It is essential to prioritize the treatment of the underlying cause of hyperbilirubinemia, rather than relying solely on albumin or other supportive measures.
Key Considerations
- Direct bilirubin elevation indicates that the liver is conjugating bilirubin properly but cannot excrete it into the bile, so treatment must target this excretion problem rather than binding capacity, which is what albumin would address.
- The use of albumin should be guided by the most recent and highest quality evidence, such as 1, which provides guidelines on the management of ascites in cirrhosis.
From the Research
Treatment of Hyperbilirubinemia
Hyperbilirubinemia, characterized by elevated direct bilirubin, can be treated using various methods. The use of albumin is one approach, given its critical role in binding bilirubin and other substances in the blood [ 2 ].
Role of Albumin
Albumin has multiple functions, including immunomodulation, endothelial stabilization, antioxidant effects, and binding multiple drugs, toxins, and other molecules [ 2 ]. In chronic liver disease, advanced cirrhosis is characterized by reduced albumin concentration and impaired albumin function due to structural changes and oxidative damage [ 2 ].
Alternative Treatments
Other treatments for hyperbilirubinemia include the use of ursodeoxycholic acid (UDCA), which has been shown to improve liver function tests in patients with chronic active hepatitis and primary biliary cirrhosis [ 3, 4, 5 ]. UDCA can reduce biochemical parameters of both cholestasis and hepatocellular damage [ 4 ] and may be beneficial in patients with non-advanced primary biliary cirrhosis [ 5 ].
Key Findings
- Albumin plays a critical role in binding bilirubin and other substances in the blood [ 2 ].
- Ursodeoxycholic acid (UDCA) can improve liver function tests in patients with chronic active hepatitis and primary biliary cirrhosis [ 3, 4, 5 ].
- The long-term evolution of bilirubin, albumin, and ALT differs from that of ALP and AST in non-advanced PBC [ 5 ].
- UDCA can be administered for at least 10 years without any adverse effects, and the treatment is safe and improves life quality [ 4 ].
Treatment Considerations
When considering treatment for hyperbilirubinemia, the following factors should be taken into account:
- The use of albumin may be beneficial in patients with chronic liver disease, particularly those with advanced cirrhosis [ 2 ].
- UDCA may be a suitable treatment option for patients with chronic active hepatitis and primary biliary cirrhosis [ 3, 4, 5 ].
- The long-term effects of UDCA on laboratory liver parameters should be carefully monitored [ 5 ].