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( liver-related and non-liver-related causes ) and duration of hospital stays ( 35 % and 45 %, respectively ). 14 The results of the ANSWER trial were further confirmed by a meta-analysis , indicating a significantly lower risk of recurrence of ascites as well as lower requirement of paracentesis in patients receiving long-term albumin administration . 15
A retrospective observational study in Indonesia showed that more than 60 % of subjects with liver cirrhosis received intravenous albumin injection . 16 Another cross-sectional study in Indonesia also highlighted the significant correlation between serum albumin level and high fasting blood glucose in patients with liver cirrhosis . 17 The fact that , in many countries , the use of albumin is still hindered by costeffectiveness might become a reason behind the lack of study in this area . Nonetheless , as has also been mentioned in the ANSWER trial , the extra cost related to albumin administration was able to be outweighed by savings from fewer paracentesis procedures , fewer hospital admissions , and shorter duration of hospital stay . 14 Similarly , another study in three developed countries emphasised the cost- effectiveness of albumin compared with SMT in patients with decompensated cirrhosis . Challenges regarding the variable definition of medical complications , classification of disease severity , and whether the cost included in the studies truly reflected the actual paid amount may still be faced in studies evaluating the cost-effectiveness of albumin in cirrhosis . 18
Conclusion In the last two decades , as albumin administration has been utilised more extensively as a pharmacologic therapeutic strategy , instead of only as a fluid therapy , it has become crucial to further the knowledge about its uses . Personalised approaches in determining effective albumin concentration , as well as how to maintain stability and functionality of commercially available albumin can be potential fields of study . Likewise , the role of albumin in mitigating intense systemic inflammation , bilirubinostasis , endothelial injury , and organ dysfunction in ACLF can also be considered as a blossoming field of study with significant potential . 19
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References 1 GBD 2017 Cirrhosis Collaborators . The global , regional , and national burden of cirrhosis by cause in 195 countries and territories , 1990 – 2017 : A systematic analysis for the Global Burden of Disease Study 2017 . Lancet Gastroenterol Hepatol 2020 ; DOI : 10.1016 / S2468- 1253 ( 19 ) 30382-6 . 2 Kamath PS , Shah VH . Overview of cirrhosis . In : Feldman M , Friedman LS , Brandt LJ ( eds ) Sleisenger and Fordtran ’ s Gastrointestinal and Liver Disease . 10th edn . Philadelphia : Elsevier , Inc 2010:1254 – 60 . 3 European Association for the Study of the Liver . EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis . J Hepatol 2018 ; DOI : 10.106 / j . jhep . 2018.03.024 . 4 Indonesian Association for the Study of the Liver . Konsensus nasional penatalaksanaan hipertensi portal di Indonesia . Jakarta : Perhimpunan
Peneliti Hati Indonesia . 2021 . 5 Theodorakopoulos T et al . Natural history of grade 1 ascites in patients with liver cirrhosis . Ann Gastroenterol 2021 ; 34:93 – 103 . 6 Tonon M et al . Outcomes and mortality of grade 1 ascites and recurrent ascites in patients with cirrhosis . Clin Gastroenterol Hepatol 2021 ; 19:358 – 66 . 7 Garcia-Tsao G . Ascites . In : Dooley JS et al ( eds ) Sherlock ’ s Disease of the Liver and Biliary System . 12th ed . Oxford : Blackwell Publishing Ltd 2011:210 – 33 . 8 Garbuzenko DV , Arefyev NO . Current approaches to the management of patients with cirrhotic ascites . World J Gastroenterol 2019 ; 25 ( 28 ): 3738 – 52 . 9 Angeli P et al . News in pathophysiology , definition , and classification of hepatorenal syndrome : A step beyond the International Club of Ascites ( ICA ) consensus document . J Hepatol 2019 ; 71:811 – 22 . 10 Ortega R et al . Terlipressin therapy with and without albumin for patients
with hepatorenal syndrome : Results of a prospective , nonrandomized study . Hepatology 2002 ; 36 ( 4 ): 941 – 8 . 11 O ’ Brien AJ et al . Prostaglandin E2 mediates immunosuppression in acutely decompensated cirrhosis . Nat Med 2014 ; 20 ( 5 ): 518 – 23 . 12 Sort P et al . Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis . N Engl J Med 1999 ; 341:403 – 9 . 13 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 ; 11:123 – 30 . 14 Caraceni P et al . Long-term albumin administration in decompensated cirrhosis ( ANSWER ): An open-label randomised trial . Lancet 2018 ; 391 : 2417 – 29 . 15 Sandi BB et al . Long-term albumin administration in patients with
cirrhosis and ascites : A meta-analysis of randomized controlled trials . J Gastroenterol Hepatol 2021 ; 36 ( 3 ): 609 – 17 . 16 Yulainda D , Maharani L , Suryoputri MW . The application of oral albumin and injection albumin in liver cirrhosis patients in RSUD Prof . Dr . Margono Soekarjo Purwokerto . Act Pharm Indo 2020 ; 8 ( 1 ): 8 – 15 . 17 Agustanti N et al . Correlation between serum albumin and fasting blood glucose level in patients with liver cirrhosis . Indo J Gastroenterol , Hepatol Digest Endoscopy 2014 ; 15 ( 3 ): 143 – 6 . 18 Runken MC et al . The costeffectiveness of albumin in the treatment of decompensated cirrhosis in Germany , Italy , and Spain . Health Econ Rev 2019 ; 9:22 . 19 Jagdish RK , Maras JS , Sarin SK . Albumin in advanced liver diseases : The good and bad of a drug . Hepatology 2021 ; 74 ( 5 ): 2848 – 62 .
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