Is Inj Hepamerz (human albumin) safe to use in a patient with chronic liver disease (CLD) and ulcerative colitis?

Use of Inj Hepamerz (Human Albumin) in Chronic Liver Disease with Ulcerative Colitis

Albumin administration is safe and appropriate in patients with chronic liver disease and ulcerative colitis when used for established liver-specific indications, but should not be used routinely for uncomplicated ascites or hypoalbuminemia correction alone. 1, 2

Established Safe Indications for Albumin in CLD

Use albumin for these specific liver-related indications regardless of concurrent ulcerative colitis:

• Large-volume paracentesis (>5L): Administer albumin at 6-8 g per liter of ascitic fluid removed to prevent paracentesis-induced circulatory dysfunction 1, 2

• Spontaneous bacterial peritonitis: Give 1.5 g/kg at diagnosis and 1.0 g/kg on day 3, which reduces mortality (10% vs 29%) and prevents hepatorenal syndrome (10% vs 33%) 1, 2

• Hepatorenal syndrome-AKI: Use albumin as the volume expander of choice in combination with vasoconstrictors like terlipressin 1, 2

• Sepsis-induced hypotension: Administer 5% albumin over normal saline, which improves 1-week survival (43.5% vs 38.3%, p=0.03) 1, 2

Contraindications and Situations to Avoid Albumin

Do not use albumin in the following scenarios:

• Uncomplicated ascites (hospitalized or outpatient): The ATTIRE trial (N=777) showed no benefit in preventing infections, kidney dysfunction, or death (OR 0.98,95% CI 0.71-1.33), with significantly higher rates of pulmonary edema in the albumin group 1

• Chronic hypoalbuminemia correction: Albumin should not be used as an intravenous nutrient or to treat stabilized hypoproteinemia in chronic cirrhosis 3

• Infections other than SBP: Three RCTs and meta-analysis confirm albumin does not reduce AKI or mortality in non-SBP infections and increases pulmonary edema risk 1

Ulcerative Colitis-Specific Considerations

The presence of ulcerative colitis does not contraindicate albumin use for established liver indications:

• Current UC treatment guidelines do not list albumin as a contraindicated medication 4

• No significant drug interactions exist between albumin and standard UC therapies including aminosalicylates, immunomodulators, biologics, or JAK inhibitors 4

• Ensure UC is in remission or well-controlled before elective albumin administration to avoid confounding GI symptoms 4

• Avoid albumin initiation during acute severe UC requiring hospitalization, as distinguishing medication side effects from disease activity becomes impossible 4

Critical Safety Monitoring

Monitor closely for volume overload complications, particularly in patients with UC who may have additional inflammatory burden:

• Watch for respiratory distress, declining oxygen saturation, and signs of pulmonary edema during and after administration 1, 2

• Assess cardiac and pulmonary function before administration, especially in patients with pre-existing cardiovascular disease 2

• Immediately discontinue albumin if pulmonary edema develops 2

• The ATTIRE trial demonstrated that targeting serum albumin >3 g/dL was associated with significantly higher rates of pulmonary edema and fluid overload 1

Practical Algorithm for Decision-Making

Step 1 - Identify the indication:

• Is this for large-volume paracentesis, SBP, hepatorenal syndrome, or sepsis-induced hypotension? If yes, proceed. If no, do not use albumin 1, 2

Step 2 - Assess UC status:

• Is UC in remission or well-controlled? If yes, proceed. If acute severe UC, defer unless life-threatening liver indication 4

Step 3 - Check contraindications:

• Assess for cardiac dysfunction, pulmonary disease, or volume overload risk. If present, use with extreme caution or avoid 2

Step 4 - Administer appropriate dose:

• LVP: 6-8 g per liter removed 1
• SBP: 1.5 g/kg day 1.0 g/kg day 3 1, 2
• HRS-AKI: Per protocol with vasoconstrictors 1

Step 5 - Monitor intensively:

• Check vital signs, oxygen saturation, and respiratory status every 4 hours during and 24 hours after infusion 2

Common Pitfalls to Avoid

• Do not use albumin to "boost" low serum albumin levels in stable cirrhosis - this practice is not evidence-based and increases complications 1, 3

• Do not assume all hypoalbuminemic patients need albumin - the ATTIRE trial definitively showed harm with this approach 1

• Do not overlook volume overload risk - patients with cirrhosis are particularly sensitive to fluid overload, and the addition of UC-related inflammation may increase capillary permeability 1, 2

• Do not confuse albumin administration with nutritional support - albumin is not an appropriate intravenous nutrient due to slow breakdown and unfavorable amino acid composition 3