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especially refractory ascites and SBP . LVP ( 4 – 5l / time / d ) combined with human albumin ( 4 – 8g / 1l ascites ) is an effective treatment method of refractory ascites . In addition , albumin infusion ( 8g / l ) can significantly reduce circulation function failure and hyponatraemia caused by abdominocentesis . 6 , 7
Human albumin supplementation ( 20 – 40g / d ) significantly improves the prognosis of patients with liver cirrhosis accompanied by refractory ascites and SBP . 1 Albumin therapy can relieve systemic inflammation and cardiac circulatory dysfunction in decompensated cirrhosis , possibly improving patients ’ prognoses . 8 Long-term albumin therapy can reduce incidence of ascites and rate of readmission , significantly improve the transplant-free survival rate and lifespan of patients with ascites while reducing the rate of recurrence . 9 A randomised controlled trial ( RCT ) showed that excessive albumin infusion ( median infusion per capita : 200g ) to attain normal albumin levels did not result in the anticipated improvements in hospitalised decompensated cirrhosis patients with acute complications and albumin levels < 30g /, but the risk of pulmonary oedema and overload fluid actually increased . 10
Albumin can effectively reduce renal injury and mortality after SBP SBP in liver cirrhosis patients with ascites is an abdominal infection and peritonitis without a clear source of abdominal lesions ( e . g ., intestinal
TABLE 1
Summary of main guideline recommendations
CMA AASLD EASL BASL
Guideline for diagnosis and treatment of ascites and relevant complications of liver cirrhosis
Diagnosis , evaluation , and management of ascites and hepatorenal syndrome
Management of decompensated liver cirrhosis
Guidelines on the management of ascites in cirrhosis
Ascites Human albumin ( 20 – 40g / d ) can improve the prognosis of ascites in patients with liver cirrhosis , especially those with refractory ascites and SBP ( evidence level : A , 1 )
Large volume paracentesis ( LVP ) ( 4 – 5l / time / d ) combined with human albumin ( 4g / l of ascites ) is an effective method of treating refractory ascites ( B , 1 )
In the case of LVP > 5l , albumin is recommended to reduce postparacentesis circulatory dysfunction risk
Based on expert consensus , recommended dose of albumin is 6 – 8g / l of ascites
For patients receiving LVP > 5l , albumin should be used as a plasma volume expander ( 8g / l of ascites ). As it is most effective , other plasma expanders are not recommended ( I ; 1 ).
For patients with LVP < 5l , albumin therapy is still recommended despite decreased PPCD risk with other plasma expanders ( III ; 1 )
If LVP > 5l , 8g albumin ( 20 % or 25 %) per litre of ascites should be infused ( high-quality evidence , strong recommendation )
For patients with acute renal injury after acute-on-chronic liver failure or puncture , 8g albumin ( 20 % or 25 %) per litre of ascites should also be considered even if LVP < 5l ( low-quality evidence , weak recommendation )
SBP
Antimicrobial agents combined with human albumin can significantly reduce case fatality rate , effectively control complications of liver cirrhosis and delay the occurrence of acute kidney injury ( AKI ).
Intravenous human albumin ( 1.5g / kg on day 1 , 1g / kg on day 3 ) based on antimicrobial agents . Patients with AKI and / or jaundice at the time of diagnosis of SBP are more likely to benefit from albumin infusion
Albumin ( 1.5g / kg at diagnosis , 1g / kg on day 3 ) ( I ; 1 )
SBP patients and / or patients with increased sCr should receive infusion of 1.5g / kg albumin within 6 hours of diagnosis and 1g / kg on day 3 ( low-quality evidence , weak recommendation )
HRS Patients with type 1 or 2 HRS can use terlipressin ( 4 – 6 h , 1mg ) combined with human albumin ( 20 – 40g / d ) for 3 d . If serum creatinine ( sCr ) does not decrease by at least 25 %, the dose can be gradually increased up to 2mg every 4 h . If effective , the treatment can be given for 7 – 14 d . If ineffective , terlipressin can be discontinued . The treatment can be repeated in case of recurrence after response
HRS – AKI can be treated with vasoconstrictors combined with albumin
For AKI of unknown causes , AKI > grade 1A or AKI induced by infection , 20 % albumin at 1g / kg ( maximum of 100g ) should be used for 2 consecutive days ( III , 1 )
For patients with AKI and tense ascites , therapeutic LVP should be combined with albumin infusion even if only small volume ascites is removed ( III , 1 )
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