The role of albumin in liver transplantation
Hypoalbuminaemia , especially following liver transplantation or for patients on the waiting list , can lead to adverse multisystem effects , and increased morbidity and mortality . This article highlights the pros and cons of albumin in liver transplantation , with the goal of supporting healthcare professionals in their daily practice and decision-making , to help ensure the best outcome for their patients
Le Trung Hieu MD MM Deputy General Secretary , Vietnam Society of Hepato-Biliary- Pancreatic Surgery ( VSHBPS ) and Department of Hepato-Biliary- Pancreatic Surgery , Liver Transplantation , Military Central Hospital 108 , Hanoi , Vietnam
Le Trung Hai MD PhD President , Vietnam Association of the Study for Liver Diseases ( VASLD ) and Vietnam Society of Hepato-Biliary-Pancreatic Surgery ( VSHBPS )
Albumin is the most abundant plasma protein in the body , comprising approximately 55 % of the total protein content . Albumin is a multi-functional protein with both colloidal and pharmacological activities . Albumin ’ s colloidal activity is essential in maintaining fluid balance between the intravascular and interstitial compartments . Because it is the predominant plasma protein , albumin accounts for approximately 70 – 80 % of plasma colloid osmotic pressure . 1
Liver transplantation is a life-saving procedure in end-stage liver disease . But the waitlist-mortality of patients with decompensated cirrhosis awaiting liver transplantation remains high owing to the occurrence of complications . To reduce the incidence of complications and improve survival , albumin represents a potentially ideal agent to expand plasma volume and has non-oncotic properties exerting potent antioxidant and immune-modulating effects , especially for the patients with decompensated cirrhosis waitlisted for liver transplantation . Reduced incidence of severe life-threatening complications would not only enhance the patient ’ s chance to undergo liver transplantation , but would also attenuate the impact of specific complications , such as renal dysfunction and hyponatraemia , on transplantation outcome . Moreover , lowering the need of hospitalisations would protect patients against the risk of nosocomial infections , which are very often caused by multi-drug resistant bacteria and have high mortality rates . 2 , 3
Albumin status also plays a very important role in liver transplantation for paediatric patients , for the status of the donor as well as for the function of the grafted liver , posttransplant treatment and outcome of the recipient and ICU time and hospital stay , as well as infectious morbidity and mortality rates . 4 The long-term prognosis of liver transplantation is now sure and 5-year survival of > 90 % is usual , with some patients alive 30 years or more after their surgery .
Albumin therapy is vital in the treatment of liver transplant patients . In liver transplantation , albumin is shifted from the circulation , presumably leaking into the interstitial space , resulting in a 30 %– 40 % decrease in plasma albumin concentration . During and after liver transplantation , exogenous albumin is infused for volume substitution and to maintain the plasma albumin concentration . 5 Maintaining serum albumin levels > 3.0g / dl can reduce the amount of haemodynamic support required in liver transplant recipients . 6
Current status of liver transplantation in Vietnam The first liver transplant in Vietnam was performed in Military Hospital 103 in January 2004 . Up to now , more than 300 liver transplants have been performed in ten centres in Vietnam , 7 including major hospitals such as the Viet Duc Hospital , Military Central Hospital 108 , Vinmec International Hospital in the capital , Hanoi , and Choray Hospital , University Medical Center in Ho Chi Minh City . Procedures comprised approximately 80 % adult liver transplantation and 20 % paediatric , as well as 75 % living donor transplantation ( including more than 65 % with donor right hepatectomy ) and 25 % deceased donor liver transplantation ( in Viet Duc Hospital ). The indications for liver transplantation were : liver cirrhosis ; hepatocellular carcinoma ( HCC ); HCC with Milan ’ s criteria ; fulminant hepatic failure ; primary biliary cirrhosis ; biliary atresia ; Wilson disease ; Budd-Chiari syndrome ; neonatal intrahepatic cholestasis caused by citrin deficiency ; and hepatitis B infection .
One-year and five-year survival rates following liver transplantation were 90 % and 75 %, respectively . Peri-operative treatment for liver transplantation included immunosuppressives , anticoagulants , antibiotics , and others , including albumin infusion . 6
Human albumin in liver transplantation Hypoalbuminaemia , which is frequently observed in 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
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