From the Guidelines
Albumin remains the preferred plasma expander for patients with cirrhosis undergoing large-volume paracentesis, due to its effectiveness in preventing post-paracentesis circulatory dysfunction and its additional benefits of reducing systemic inflammation, improving immune function, and binding toxins 1. When albumin is unavailable, synthetic colloids like hydroxyethyl starch (HES) and dextran can be used at 6-8 g per liter of ascitic fluid removed. For hepatorenal syndrome, terlipressin (0.5-2 mg IV every 4-6 hours) with albumin is standard, but norepinephrine (0.5-3 mg/hour) can substitute when terlipressin isn't available 1. Some key points to consider when using alternatives to albumin include:
- Synthetic colloids carry risks of coagulopathy, renal dysfunction, and anaphylaxis, making them second-line options when albumin is unavailable or contraindicated.
- Crystalloid solutions such as normal saline and lactated Ringer's may be used if albumin is unavailable, but they are generally less effective than albumin.
- Vasoconstrictors like terlipressin, norepinephrine, and midodrine plus octreotide can be used to maintain intravascular volume and prevent post-paracentesis circulatory dysfunction or hepatorenal syndrome. The most recent and highest quality study, published in 2021, found that albumin was more effective than alternative plasma expanders in preventing post-paracentesis circulatory dysfunction and improving outcomes in patients with cirrhosis 1. Therefore, albumin should be used as the first-line treatment for patients with cirrhosis undergoing large-volume paracentesis, and alternatives should only be considered when albumin is unavailable or contraindicated.
From the Research
Alternatives to Albumin in the Treatment of Cirrhosis
- Midodrine, a vasoconstrictor, has been shown to improve splanchnic and systemic hemodynamics, reduce ascites, and improve clinical outcomes in patients with cirrhosis and ascites 2.
- Octreotide, in combination with midodrine and albumin, has been found to improve survival in patients with type 1 and type 2 hepatorenal syndrome 3.
- A standardized approach using albumin, midodrine, and octreotide has been shown to trend towards improved treatment response rates in patients with hepatorenal syndrome, with significantly lower rates of renal replacement therapy and liver transplantation 4.
Plasma Expanders as Alternatives to Albumin
- Plasma expanders such as dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared to albumin in patients with cirrhosis and large ascites, with no significant difference in effect on mortality, renal impairment, or other liver-related complications 5.
- Midodrine has been found to be non-inferior to albumin in improving clinical parameters in patients with cirrhotic ascites 2.
Combination Therapies
- The combination of midodrine, octreotide, and albumin has been shown to improve renal function and short-term survival in patients with hepatorenal syndrome 6, 3.
- The use of midodrine, octreotide, and albumin in combination with TIPS (transjugular intrahepatic portosystemic stent shunt) has been found to be effective in treating type 1 hepatorenal syndrome in selected patients with cirrhosis and ascites 6.