What is the role of albumin (human albumin) in cirrhosis (liver disease), including its indications and contraindications?

Role of Albumin in Chronic Liver Disease: Indications and Contraindications

Albumin administration in cirrhosis should be limited to specific evidence-based indications including large-volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome, while avoiding use in uncomplicated ascites or non-SBP infections due to lack of benefit and potential harm. 1

Established Indications for Albumin in Cirrhosis

1. Large-Volume Paracentesis (LVP)

• Strong recommendation: Administer albumin at 8g per liter of ascites removed for paracentesis >5L 2
• Benefits:
  • Reduces paracentesis-induced circulatory dysfunction (PICD) by 61% 2
  • Decreases mortality by 36-47% 2
  • Prevents rapid re-accumulation of ascitic fluid 3
• Dosing: 20% or 25% albumin solution administered after completing paracentesis 2
• Consider albumin even for paracentesis <5L in patients with acute-on-chronic liver failure (ACLF) 2

2. Spontaneous Bacterial Peritonitis (SBP)

• Strong recommendation: Administer albumin with antibiotics in SBP 1
• Dosing: 1.5 g/kg at diagnosis (day 1) and 1g/kg on day 3 1, 2
• Benefits:
  • Reduces incidence of type 1 hepatorenal syndrome (from 30% to 10%) 1
  • Reduces mortality (from 29% to 10%) 1
  • Decreases risk of AKI by 72% 2
• Patients with baseline serum bilirubin >4 mg/dL or creatinine >1.0 mg/dL are at highest risk and most likely to benefit 1
• Lower doses (10g/day for 3 days) may still be effective in reducing renal dysfunction and mortality 1

3. Hepatorenal Syndrome (HRS)

• Strong recommendation: Albumin is a key component of HRS management 1
• Typically used in conjunction with vasoconstrictors (terlipressin) 1
• Dosing: 8g per liter of ascites extracted 2

Contraindications and Non-Recommended Uses

1. Uncomplicated Ascites

• Do not use albumin in patients with cirrhosis and uncomplicated ascites (hospitalized or outpatient) 1
• Multiple studies show:
  • No improvement in control of ascites with albumin 1
  • Failure to enhance diuretic effect of furosemide 1
  • Conflicting evidence on long-term administration 1
  • ATTIRE trial showed no benefit in preventing infection, AKI, or death 1

2. Non-SBP Infections

• Do not use albumin in cirrhotic patients with infections other than SBP 1
• Evidence shows:
  • No reduction in risk of AKI or mortality 1
  • Associated with more pulmonary edema 1
  • Only consider if associated with AKI 1

3. Targeting Specific Serum Albumin Levels

• Not recommended: Targeting specific serum albumin levels (e.g., >3.0 g/L) 1
• ATTIRE trial showed:
  • No difference in composite outcomes (infection, renal failure, death) 1
  • Higher rates of pulmonary edema and fluid overload 1

Special Considerations

Potential Adverse Effects

• Pulmonary edema and fluid overload, particularly with excessive doses (>87.5g) 2
• Administer albumin infusion slowly to prevent cardiac overload 2
• Monitor for allergic reactions, transfusion reactions, and coagulation derangements 4

Mechanisms of Action

• Beyond oncotic effects, albumin has important non-oncotic properties 5, 6:
  • Binds lipopolysaccharide and other bacterial products 6
  • Scavenges reactive oxygen species and nitric oxide 6
  • Modulates inflammatory reactions 6
  • Improves functionality of immune cells 4

Cost and Resource Considerations

• Albumin is expensive and has limited availability 4
• Requires healthcare setting for administration 4
• Use judiciously based on evidence-based indications 4

Emerging Research

• Potential role in:
  • Acute-on-chronic liver failure 5
  • Hepatic encephalopathy 5
  • Hyponatremia 5
• Ongoing trials will provide additional clarity on the role of albumin in various settings 1

In summary, while albumin has clear benefits in specific scenarios (LVP, SBP, HRS), its use should be restricted to these evidence-based indications to maximize benefit while avoiding potential harm and unnecessary costs.