Human albumin : management of liver disease
Albumin is effective in the prevention and treatment of specific complications of cirrhosis due to its oncotic and non-oncotic properties
NOTE This chapter discusses common clinical uses of albumin in liver disease and not all brands of albumin approved by the FDA are labeled for these indications
The presence of hypoalbuminemia is a typical feature of cirrhosis and an important adverse prognostic factor . Studies have clearly established that albumin is effective in counteracting the hemodynamic dysfunction of advanced cirrhosis , which occurs as a result of arterial vasodilation mainly in the splanchnic area and represents the common background for several complications . 1 The beneficial effects of albumin are most likely due not only to volume expansion , but also its non-oncotic properties such as anti-oxidant and scavenger activities , and its ability to modulate immune responses and preserve capillary integrity and permeability . 1 These non-oncotic properties assume even more relevance in the light of several investigations showing that in patients with advanced cirrhosis , serum albumin undergoes several molecular alterations that endanger these functions . 2 – 5 Moreover , the pathophysiological background of decompensated cirrhosis is characterized by a sustained pro-inflammatory and pro-oxidant state responsible for cardiovascular and multiorgan dysfunction . 6 Due to the several beneficial effects , albumin is widely used in patients with liver disease and cirrhosis .
Indications for albumin administration in cirrhosis Prevention of renal failure in spontaneous bacterial peritonitis Spontaneous bacterial peritonitis ( SBP ) is a frequent and life-threatening infection of ascitic fluid and diagnosed based on finding more than 250 polymorphonuclear cells / mm 3 in ascitic fluid , in the absence of an intra-abdominal source of infection or malignancy . 7 Studies have investigated SBP-related in-hospital mortality rates , which can be high despite the resolution of infection . 7 Even without the occurrence of septic shock , SBP leads to a proinflammatory cytokine storm that further impairs cardiovascular dysfunction . The ensuing worsening in effective volemia can lead to acute kidney injury ( AKI ), with the phenotype of hepatorenal syndrome ( HRS ) or acute tubular necrosis ( ATN ), accounting for more than 80 % of AKI cases in this patient population . 8 A prospective randomized study has shown the administration of a high dose of albumin ( 1.5g / kg ) at diagnosis and 1g / kg on day 3 in addition to antibiotic treatment , decreases the incidence of renal failure ( from 30 % to 10 %) and improves inhospital and three-month survival . 9 The capacity of albumin to improve the outcome of patients with SBP has been confirmed in a meta-analysis of four randomized trials . The results revealed that the odds ratio for renal impairment after albumin infusion ranged between 0.19 and 0.30 and a pooled odds ratio for decreased mortality of 0.34 . 10 As a result , the European Association for the Study of the Liver and the American Association for the Study of Liver both recommend that all patients with SBP should receive intravenous albumin at the higher dosage in
11 , 12 addition to antibiotics .
Diagnosis and treatment of hepatorenal syndrome Hepatorenal syndrome ( HRS ) is a potentially reversible AKI that occurs in patients with advanced cirrhosis , ascites and liver failure and is associated with marked circulatory dysfunction . 8 HRS is the clinical manifestation of a severe intra-renal vasoconstriction and occurs due to impaired volemia secondary to both arterial vasodilation and cardiac dysfunction ( cirrhotic cardiomyopathy ). These changes lead to a striking compensatory activation of vasoconstrictor systems such as the renin – angiotensin system , sympathetic nervous system and arginine vasopressin . 13 Moreover , inflammationinduced kidney damage likely plays a relevant concomitant role . 6
In making a diagnosis of HRS , it is necessary to exclude other forms of AKI 8 , 11 and any diuretic treatment should be withdrawn . Differentiating HRS and pre-renal AKI is based on a failure to improve serum creatinine after two days of plasma volume expansion , which is preferentially performed
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