Human albumin : Focus on liver disease
Tong Rongsheng Department of Pharmacy , Sichuan Provincial People ’ s Hospital , Chengdu 610072
Xu Xiaoyuan Department of Infectious Disease , Peking University First Hospital , Beijing 100034
References 1 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators . Global , regional , and national incidence , prevalence , and years lived with disability for 354 diseases and injuries for 195 countries and territories , 1990 – 2017 : a systematic analysis for the Global Burden of Disease Study 2017 . Lancet 2018 ; 392 ( 10159 ): 1789 – 858 . 2 D ’ Amico G , Garcia-Tsao G , Pagliaro , L . Natural history and prognostic indicators of survival in cirrhosis : A systematic review of 118 studies . J Hepatol 2006 ; 44:217 – 31 . 3 Caraceni P et al . Long-term albumin administration in decompensated cirrhosis ( ANSWER ): an open-label randomised trial . Lancet 2018 ; 391 ( 10138 ): 2417 – 29 . 4 Di Pascoli M et al . Long-term administration of human albumin improves survival in patients with cirrhosis and refractory ascites . Liver Int 2019 ; 39 ( 1 ): 98 – 105 . 5 Fernandez J et al . Effects of albumin treatment on systemic and portal hemodynamics and systemic inflammation in patients with decompensated cirrhosis . Gastroenterology 2019 ; 57 ( 1 ): 149 – 62 . 6 Caraceni P , et al . AISF-SIMTI position paper on the appropriate use of albumin in patients with liver cirrhosis : a 2020 update . Blood Transfus 2021 ; 19 ( 1 ): 9 – 13 . 7 Bernardi M , Caraceni P . Novel perspectives in the management of decompensated cirrhosis . Nat Rev Gastroenterol Hepatol 2018 ; 15 ( 12 ): 753 – 64 .
The cumulative prevalence of liver diseases , especially chronic liver diseases , which is increasing year by year , is an unprecedented global health burden . According to the Global Burden of Disease Study in 2017 , the number of patients with liver cirrhosis and other chronic liver diseases exceeded 1.5 billion worldwide , and the number of deaths caused by liver cirrhosis reached 1.32 million . 1 Albumin , synthesised in the liver , accounts for 70 %– 80 % of plasma osmotic pressure . In patients with liver cirrhosis and liver failure , albumin infusion can improve haemodynamic disorders and circulatory dysfunction caused by liver cirrhosis by increasing effective circulating blood volume . Meanwhile , hypoalbuminaemia is a good prognostic indicator of both mortality and morbidity in decompensated cirrhosis . 2 Determining the relevant patient populations and clinical settings are vital prerequisites to optimising the value of human albumin therapy ; Hospital Pharmacy International has therefore invited hepatologists , infectious disease specialists , oncologists , and experts in liver transplantation across China ( and Vietnam ) to discuss the clinical management of liver cirrhosis and its various complications , liver cancer , liver transplantation and other common liver diseases . They share their clinical experiences and opinions in this educational handbook , with the aim of imparting and disseminating knowledge with colleagues across China and beyond .
Before liver fibrosis and cirrhosis advance to endof-life events such as acute-on-chronic liver failure , hepatocellular carcinoma , and death , patients often experience a long course of disease progression . Decompensated cirrhosis , as a landmark event in the progression of chronic liver disease , is accompanied by a series of complications , including liver ascites , spontaneous bacterial peritonitis , hepatorenal syndrome , etc ., that worsen patients ’ prognoses and increase the complexity of clinical management .
In recent years , concepts for the treatment of decompensated cirrhosis have continued to change internationally , evolving from the clinical management of specific complications of interest to multiple interventions in decompensated cirrhosis . According to the latest academic opinion , risk factors ( such as viral infection , alcohol use , etc ) can lead to core pathological events including portal hypertension and bacterial translocation , which subsequently further trigger multiple complex pathological mechanisms , such as circulatory dysfunction and immune dysfunction , etc .
The multiple biological effects of human albumin parallel the pathological mechanisms of decompensated cirrhosis . Based on this , a number of high-quality clinical studies ( such as the ANSWER study ) have investigated and confirmed the therapeutic benefits of long-term human albumin infusion in patients with decompensated cirrhosis . 3 – 5 These evidence-based practices have extended the indications of albumin use to liver cirrhosis , and supported an update of the European AISF-SIMTI position paper on the appropriate use of albumin in patients with liver cirrhosis . 6 The therapeutic effects of human albumin in the complications of decompensated cirrhosis are not only derived from relatively low blood volume resulting from its colloidal effect against portal hypertension and dilatation of small arteries , but also , in the early stage of the disease , its multiple involvements in downstream pathological mechanisms . 7
The clinical management of early liver cancer is also extremely complicated . Different from advanced liver cancer where systemic treatment is the main treatment modality , patients with early liver cancer can undergo radical surgical resection . However , in addition to the complete resection of the entire lesion , there are many factors that affect the overall prognosis of the patients after surgery , including pre-operative liver function reserve and perioperative serum albumin levels . Abnormal liver function in patients with liver cancer can greatly affect albumin synthesis . At the same time , bleeding and tissue trauma resulting from surgery can accelerate the loss of serum albumin . Therefore , hypoalbuminaemic patients should receive albumin during the perioperative period , which will improve their overall prognoses after surgery .
If indicated , liver transplantation is the best treatment for liver cirrhosis and hepatocellular carcinoma . However , liver transplantation , being a very difficult procedure , requires close and intricate perioperative management to ensure the clinical benefits after surgery . Patients undergoing liver transplantation often experience hypoalbuminaemia , which is an important prognostic factor . The in vivo pharmacokinetic properties of immunosuppressants used after transplantation can also be affected by serum albumin levels , and hypoalbuminaemia can result in therapeutic toxicity that is not conducive to a good overall clinical prognosis .
In summary , liver disease is characterised by complex clinical features , heterogeneous patient populations , and multiple pathological mechanisms . To improve patient outcomes , the standardisation of clinical treatments in the relevant populations and improvements in overall prognoses are urgently required . hospitalpharmacyeurope . com | 2021 | 3