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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

Fernandez et al : Hepatology 2005 20 % albumin 6 % HES 200 / 0.5 Not significant

Chen et al Scand J Gastroenterol 2009 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

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 with the administration of

12 – 14 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 post-procedure . 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 effusion . In general , the high incidence of drainage-relevant pleural effusions might be explained by low serum albumin levels and postoperative hypoproteinaemia . ¹⁹ The direct impact of hypoalbuminaemia on pleural effusion has not been definitively identified because of the coexistence of additional risk factors for the development of pleural effusion : such as high rates of intraoperative blood and fluid transfusions associated with postoperative pulmonary complications and early postoperative pneumonia , and local mechanisms at the right side of the diaphragm probably playing an additional role . ²⁰ A large study of 2316 liver donors revealed that early postoperative hypoalbuminaemia has an impact on postoperative complications such as pleural effusion ,

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