Sponsored: Human albumin: Liver Disease SE Asia - Page 10

of HRS are shown in Table 1 .
Prevention of paracentesis-induced circulatory dysfunction Paracentesis-induced circulatory dysfunction ( PICD ) is a hyperdynamic state as a complication of large-volume paracentesis ( LVP ) (> 5l ) secondary to activation of the renin – angiotensin system . 14 Within six days of LVP , there is a rapid return of ascites , HRS , and hyponatraemia . The incidence of PICD is up to 80 % when LVP is performed without subsequent plasma volume expansion ; however , it decreases to 18 % upon
14 , 15
administration of albumin . According to guidelines , LVP is the first-line therapy in patients with significant ascites ( grade 3 ascites ). 11 , 16 When LVP ( removal of > 5l ascitic fluid ) is performed , albumin
11 , 16
administration at a dose of 8g / l is recommended .
The main clinical trials of albumin in PICD are shown in Table 2 .
Prevention of spontaneous bacterial peritonitis Most patients with spontaneous bacterial peritonitis ( SBP ) will progress to renal impairment despite the use of nonnephrotoxic antibiotics . Renal failure in SBP occurs in an intense inflammatory response setting . The inflammatory response shows extremely high plasma and ascitic fluid levels of proinflammatory cytokines such as tumour necrosis factor-alpha and signs of systemic inflammatory response syndrome with dilutional hyponatraemia . 18 The development of renal dysfunction predisposes patients to increased liver-related morbidity and mortality . 18 A meta-analysis of four randomised , controlled trials showed that albumin infusion prevented renal impairment and reduced mortality among patients with SBP . 19
The main clinical trials in SBP are shown in Table 3 .
ACLF Human albumin can be used for artificial liver support in patients with hepatic failure . Patients with ACLF and hepatic encephalopathy can receive high-dose plasmapheresis or albumin dialysis . 23 In 2020 , the Society of Critical Care Medicine proposed that albumin can be used for fluid resuscitation in patients with acute liver failure or ACLF . When serum albumin is < 3mg / dl , a dose of 1.2 – 2.0g / kg / day , equivalent to that for critical patients without hepatic failure , is recommended . 24
Long-term albumin treatment in decompensated cirrhosis With the above-mentioned benefits of albumin , the use of long-term albumin infusion to modify the development of liver-related complications remains a promising option and is discussed in detail later in this handbook .
Conclusion Hypoalbuminaemia is associated with a significant morbidity and mortality risk for a range of patient populations and these risks are generally linked to a reduced functional capacity of the protein . Moreover , corrective action to normalise serum albumin levels mitigates these risks . The available data suggest that albumin , when incorporated into the standard care of hepatic patients , can prevent PICD , treat SBP , and prevent HRS . Evidence points to a potential survival benefit with long-term albumin therapy in patients with decompensated cirrhosis . However , more studies are needed to better understand albumin biology and integrate these findings into future and ongoing clinical trials .
References 1 Yoshida K , Seto-Ohshima A , Sinohara H . Sequencing of cDNA encoding serum albumin and its extrahepatic synthesis in the Mongolian gerbil , Meriones unguiculatus . DNA Res 1997 ; 4 ( 5 ): 351 – 4 . 2 Gatta , A , Verardo A , Bolognesi , M . Hypoalbuminemia . Intern Emerg Med 2012 ; 7:193 – 9 . 3 Jellinge ME et al . Hypoalbuminaemia is a strong predictor of 30-day allcause mortality in acutely admitted medical patients : a prospective , observational , cohort study . PLoS One 2014 ; 9 ( 8 ): e105983 . 4 Gibbs J et al . Preoperative serum albumin level as a predictor of operative mortality and morbidity : results from the National VA Surgical Risk Study . Arch Surg 1999 ; 134 ( 1 ): 36 – 42 . 5 Akirov A et al . Low albumin levels are associated with mortality risk in hospitalised patients . Am J Med 2017 ; 130 ( 12 ): 1465 . e11-1465 . 6 Wiedermann CJ et al . Hypoalbuminemia and acute kidney injury : a meta-analysis of observational clinical studies . Intensive Care Med 2010 ; 36 ( 10 ): 1657 – 65 . 7 Engelman DT et al . Impact of body mass index and albumin on morbidity and mortality after cardiac surgery . J
Thorac Cardiovasc Surg 1999 ; 118 ( 5 ): 866 – 73 . 8 Gupta D , Lis CG . Pre-treatment serum albumin as a predictor of cancer survival : A systematic review of the epidemiological literature . Nutr J 2010 ; 9:69 . 9 Global Health Estimates . Geneva : World Health Organization ; 2016 www . who . int / healthinfo / global _ burden _ disease / estimates / en / ( accessed February 2022 ). 10 Levitt DG , Levitt MD . Human serum albumin homeostasis : a new look at the roles of synthesis , catabolism , renal and gastrointestinal excretion , and the clinical value of serum albumin measurements . Int J Gen Med 2016 ; 9:229 . 11 European Association for The Study Of The Liver . EASL clinical practice guidelines on the management of ascites , spontaneous bacterial peritonitis , and hepatorenal syndrome in cirrhosis . J Hepatol 2010 ; 53 ( 3 ): 397 – 417 . 12 Wong F et al . Terlipressin plus Albumin for the treatment of type 1 hepatorenal syndrome . N Engl J Med 2021 ; 384 ( 9 ): 818 – 28 . 13 Sanyal AJ et al . Reversal of hepatorenal syndrome type 1 with terlipressin plus Albumin vs . placebo
plus Albumin in a pooled analysis of the OT-0401 and REVERSE randomized clinical studies . Aliment Pharmacol Ther 2017 ; 45 ( 11 ): 1390 – 402 . 14 Arora V et al . Paracentesis- Induced Circulatory Dysfunction With Modest-Volume Paracentesis Is Partly Ameliorated by Albumin Infusion in Acute-on-Chronic Liver Failure . Hepatology 2020 ; 72 ( 3 ): 1043 – 55 . 15 Simon DM et al . Effects of therapeutic paracentesis on systemic and hepatic hemodynamics and renal and hormonal function . Hepatology 1987 ; 7 ( 3 ): 423 – 9 . 16 Runyon BA . AASLD practice guideline . Management of adult patients with ascites due to cirrhosis update 2012 . American Association Study of Liver Disease Update 2012 . 17 Alessandria C et al . Prevention of paracentesis-induced circulatory dysfunction in cirrhosis : standard vs half albumin doses . A prospective , randomized , unblinded pilot study . Digest Liv Dis 2011 ; 43 ( 11 ): 881 – 6 . 18 Ruiz-del-Arbol L et al . Systemic , renal , and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis . Hepatology 2003 ; 38 ( 5 ): 1210 – 18 . 19 Salerno F , Navickis RJ , Wilkes MM . Albumin infusion improves
outcomes of patients with spontaneous bacterial peritonitis : a meta-analysis of randomized trials . Clin Gastroenterol Hepatol 2013 ; 11 ( 2 ): 123 – 30 . 20 Thévenot T et al . Effect of Albumin in cirrhotic patients with infection other than spontaneous bacterial peritonitis . A randomized trial . J Hepatol 2015 ; 62 ( 4 ): 822 – 30 . 21 Guevara M et al . Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis . A randomized , controlled study . J Hepatol 2012 ; 57 ( 4 ): 759 – 65 . 22 Fernández J et al . Efficacy of albumin treatment for patients with cirrhosis and infections unrelated to spontaneous bacterial peritonitis . Clin Gastroenterol Hepatol 2020 ; 18 ( 4 ): 963 – 73 . 23 Sarin SK et al . Correction to : Acuteon-chronic liver failure : consensus recommendations of the Asian Pacific Association for the Study of the Liver ( APASL ): an update . Hepatol Int 2019 ; 13 ( 6 ): 826 – 8 . 24 Nanchal R et al . Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU : Cardiovascular , endocrine , hematologic , pulmonary , and renal considerations . Crit Care Med 2020 ; 48 ( 3 ): e173 – e91 .
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