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hospitalised patients , is present in various diseases , including cirrhosis , malnutrition , nephrotic syndrome and sepsis . Regardless of its cause , hypoalbuminaemia has strong predictive value in terms of mortality and morbidity . Postoperative hypoalbuminaemia is common in liver transplant recipients and is used as an indicator of postoperative outcome . The negative effects of postoperative hypoalbuminaemia have been long known and several papers have addressed this . 8
The primary immunosuppressive drug used after liver transplantation – tacrolimus – has low extraction and is bound extensively in plasma , predominantly to albumin . 9 In the early recovery period after transplantation , the combination of hepatic impairment and hypoalbuminaemia might theoretically predispose patients to excess toxicity during tacrolimus therapy , even in the presence of apparently therapeutic or subtherapeutic total blood concentrations of the drug . Trull et al 10 demonstrated that there was an increased incidence of tacrolimus nephrotoxicity among liver transplant recipients with impaired hepatic metabolism and low serum albumin levels . They found that the use of human albumin to maintain serum albumin levels of 2.5g / dl was associated with a rate of treated acute rejection episodes during the first postoperative month ; a concentration of 25g / l is considered necessary for immunosuppressive drugs to be effective . 11
Current international guidelines provide specific indications on the use of albumin in cirrhosis , especially on the waiting list for liver transplant : prevention of paracentesis-induced circulatory dysfunction and its clinical consequences , prevention of renal dysfunction in patients with spontaneous bacterial peritonitis ( SBP ) and treatment of hepatorenal syndrome ( HRS ) associated
12 – 14 with the administration of vasoconstrictors .
It is believed that maintaining higher albumin levels reduce the amount of abdominal or thoracic fluid collection in transplant recipients . Traditionally , in many hospitals , the amount of serum albumin and crystalloids administered depends on the abdominal drainage volume , the aim being to maintain intravascular volume postprocedure . Ito et al 15 found that low postoperative albumin levels are likely to cause ascites and prolong hospital stays following liver resections for liver cancer . Ertmer et al 16 demonstrated that continuous infusion of albumin might preserve cumulative organ function ( as measured by Sequential Organ Failure Assessment scores ), especially cardiovascular function , in patients undergoing orthotopic liver transplantation . Surgical stress and delayed graft function are likely associated with the decrease in serum albumin levels in liver transplant recipients . Albumin offers several benefits : it scavenges radical oxygen species ; has anticoagulant properties ; limits tubular cell apoptosis ; is intimately related to fluid movement across the endothelial barrier ; and is central to maintaining adequate microvascular blood flow . 17
Studies have demonstrated that early postoperative hypoalbuminaemia is associated with postoperative complications . 18 The most common postoperative pulmonary complication following liver transplantation is pleural
TABLE 1
Summary of some randomised trials studying albumin treatment during spontaneous bacterial peritonitis , sepsis , and in the general ICU population with sepsis
Spontaneous bacterial peritonitis ( SBP )
Trial
Treatment
Control
Mortality albumin vs
control
Sort et al : N Engl J Med 1999
Xue et al : Chin J Gastroenterol 2001
Fernandez et al : Hepatology 2005
Chen et al Scand J Gastroenterol 2009
20 % albumin
Cefotaxime alone
Favours albumin
( 22 % vs 41 %; p = 0.03 )
20 % albumin
Ceftriaxone alone
Favours albumin
( 10 % vs 34 %; p = 0.002 ]
20 % albumin 6 % HES 200 / 0.5 Not significant
20 % albumin Antibiotics alone Not significant
Sepsis other than SBP in cirrhosis
Guevara et al : J Hepatol 2012
Thévenot et al : J Hepatol 2015
20 % albumin Antibiotics alone Not significant
20 % albumin Antibiotics alone Not significant
Sepsis and septic shock in general ICU population
SAFE study : N Engl J Med 2004
ALBIOS study : N Engl J Med 2014
4 % albumin NaCl 0.9 % Not significant
20 % albumin Crystalloids Not significant
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