What are the indications for human albumin in patients with decompensated liver cirrhosis?

Indications for Human Albumin in Decompensated Liver Cirrhosis

Human albumin is strongly recommended for three specific indications in decompensated cirrhosis: large-volume paracentesis (>5L), spontaneous bacterial peritonitis, and hepatorenal syndrome. 1

Established Indications with Strong Evidence

Large-Volume Paracentesis (>5 Liters)

Albumin at 8 g per liter of ascites removed should be administered after completing paracentesis of more than 5 liters. 1, 2, 3

• Use 20% or 25% albumin solution infused after the procedure is completed, not during 1, 2
• This prevents post-paracentesis circulatory dysfunction (PPCD), which occurs in up to 80% of patients without albumin but only 18.5% with albumin 3, 4
• Albumin reduces the odds of PPCD by 60% compared to other plasma expanders 4
• High-quality evidence demonstrates significant reduction in adverse effects including renal impairment, hyponatremia (42% reduction), and mortality (36% reduction) 2, 3, 4

For paracentesis <5 liters, albumin can be considered in high-risk patients (those with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury), but is not mandatory 1, 2, 5

Spontaneous Bacterial Peritonitis (SBP)

Administer 1.5 g/kg albumin within 6 hours of SBP diagnosis, followed by 1.0 g/kg on day 3. 1, 2, 5

• This protocol reduces hepatorenal syndrome development and mortality 2
• Patients with serum bilirubin >4 mg/dL or creatinine >1.0 mg/dL benefit most 2
• This is a weak recommendation based on low-quality evidence, but represents standard of care 1

Hepatorenal Syndrome (HRS)

Albumin is recommended in combination with vasoconstrictors for management of HRS. 1, 6

• This indication is well-established in guidelines 1
• Albumin improves survival when used for HRS prevention and treatment 7

Indications NOT Supported by Evidence

Routine Hypoalbuminemia Correction

Do not use albumin routinely to correct hypoalbuminemia or maintain specific serum albumin levels in hospitalized patients with decompensated cirrhosis. 1

• The ATTIRE trial (777 patients) showed no benefit in the composite endpoint of infection, renal failure, or death when targeting serum albumin of 3 g/dL 1
• Targeting specific albumin levels was associated with significantly higher rates of pulmonary edema and fluid overload 1
• This represents high-quality recent evidence that should guide practice 1

Non-SBP Infections

Albumin should not be used for extraperitoneal infections (pneumonia, urinary tract infections, etc.) in cirrhotic patients. 1, 2

• No evidence of benefit in reducing acute kidney injury or mortality 2
• Associated with increased pulmonary edema 2

Sepsis-Induced Hypotension: Conflicting Evidence

The evidence for albumin in sepsis-induced hypotension among cirrhotic patients is mixed:

• One RCT (308 patients) showed 5% albumin improved 1-week survival compared to normal saline (43.5% vs 38.3%, p=0.03) 1
• Another RCT (100 patients) showed 20% albumin had higher shock reversal rates but no survival benefit and increased pulmonary complications 1
• Given conflicting evidence and safety concerns, albumin's broader use as a resuscitation agent in critically ill cirrhotic patients is not well-defined and cannot be routinely recommended 1

Mechanism of Benefit Beyond Oncotic Effects

Albumin provides benefits through both oncotic and non-oncotic properties 6, 7:

• Binds lipopolysaccharide and bacterial products, modulating inflammatory response 7
• Acts as antioxidant and radical scavenger 6, 7
• Provides immunomodulatory effects 6, 7
• These properties explain why albumin reduces systemic inflammation and circulatory dysfunction in decompensated cirrhosis 1, 6

Critical Pitfalls to Avoid

Do not use alternative plasma expanders (dextran-70, polygeline, hydroxyethyl starch) instead of albumin for large-volume paracentesis >5L - they are inferior in preventing PPCD and associated with higher activation of renin-angiotensin-aldosterone system 2, 3, 4

Do not withhold paracentesis due to coagulopathy - routine correction of INR or platelet count before paracentesis is not recommended, even with significant abnormalities 1, 3

Do not leave paracentesis drains in overnight 3