What are the indications for albumin in patients with Portal Blood Encephalopathy (PBE)?

Indications for Albumin in Patients with Portal Blood Encephalopathy (PBE)

Albumin administration is recommended for patients with hepatic encephalopathy in combination with standard therapy (lactulose) to improve resolution of encephalopathy and reduce mortality. 1

Evidence for Albumin Use in Hepatic Encephalopathy

• A 2021 systematic review identified two randomized controlled trials (N=176) showing that albumin administration resulted in a reduction in hepatic encephalopathy (RR 0.60; 95% CI 0.38-0.95) and mortality (RR 0.54; 95% CI 0.33-0.90) 1

• The first open-label trial (N=120) showed that albumin (1.5 g/kg/day for up to 10 days) plus lactulose achieved complete resolution of hepatic encephalopathy in 75% of patients versus 53% with lactulose alone (P=0.03) 1

• The same trial demonstrated reduced mortality at day 10 (18% vs 32%, P=0.04) in the albumin-lactulose group compared to lactulose alone 1

• A second masked RCT (N=56) using albumin (1.5 g/kg on day 1 and 1.0 g/kg on day 3) showed improved 90-day mortality (23% vs 47%) and transplant-free survival compared to normal saline (P=0.02) 1

• A more recent meta-analysis (2023) confirmed that albumin may reduce mortality risk in cirrhotic patients with hepatic encephalopathy (low certainty evidence) 2

Recommended Dosing Regimens

• For acute hepatic encephalopathy: 1.5 g/kg on day 1 followed by 1.0 g/kg on day 3 1

• Alternative regimen: 1.5 g/kg/day for up to 10 days in combination with lactulose 1

• For outpatients with hepatic encephalopathy: Weekly hyperoncotic albumin for 5 weeks has shown improvements in cognitive function 1

Important Considerations and Limitations

• The large Albumin to Prevent Infection in Chronic Liver Failure trial subgroup analysis (N=149) did not show improvement in the composite endpoint of new infections, kidney dysfunction, or death between days 3 and 15 in patients with hepatic encephalopathy (adjusted OR 0.91; 95% CI 0.44-1.86) 1

• Potential adverse effects of albumin administration include 3:

  • Fluid overload and pulmonary edema (particularly in patients with compromised cardiac or pulmonary function)
  • Hypotension and tachycardia
  • Hemodilution requiring RBC transfusion
  • Anaphylactic/allergic reactions

• Patients with cirrhosis are at higher risk for adverse effects due to increased capillary permeability 3

• More severe or life-threatening serious adverse events have been reported in albumin-treated patients, primarily pulmonary edema 1

Other Established Indications for Albumin in Cirrhosis

While not specific to hepatic encephalopathy, albumin is also indicated in cirrhotic patients for:

• Prevention of circulatory dysfunction after large-volume paracentesis (>5L) 1, 4

• Prevention of hepatorenal syndrome in patients with spontaneous bacterial peritonitis (1.5 g/kg at diagnosis and 1g/kg on day 3) 1

• Treatment of established hepatorenal syndrome in conjunction with vasoconstrictors 5

Clinical Decision Algorithm

1. Confirm diagnosis of hepatic encephalopathy in a patient with cirrhosis
2. Initiate standard therapy (lactulose)
3. Consider albumin administration if:
   • Patient has moderate to severe encephalopathy
   • Patient has additional risk factors (serum bilirubin ≥68 μmol/L or serum creatinine ≥88 μmol/L)
4. Administer albumin using one of the recommended dosing regimens
5. Monitor closely for:
   • Resolution of encephalopathy
   • Signs of fluid overload or pulmonary edema
   • Allergic reactions
6. Reassess at 48-72 hours to evaluate response and need for continued therapy

The evidence suggests that albumin administration can be beneficial in patients with hepatic encephalopathy, but careful patient selection and monitoring are essential to maximize benefits while minimizing risks 1, 3.