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suggesting a close relationship between low albumin level and surgical stress or trauma that can predict adverse clinical outcomes after donor hepatectomy or liver transplantation . 18 Ascites is the most frequent complication of cirrhosis , occurring in 7 – 10 % of compensated cirrhosis liver patients every year . SBP is an infection of ascitic fluid in the absence of any intra-abdominal , surgically treatable source of infection . Despite timely diagnosis and treatment its reported incidence in ascitic patients varies between 7 % and 30 %. 12 Because infection in the early post-transplant period is a major cause of morbidity and mortality , and the use of high-dose immunosuppression might limit the ability to control even sensitive infections , the general consensus is that fully treating an infection before transplant is the optimal approach when possible . Although evidence is not clear , total protein concentration < 1.5g / dl is considered a risk factor for SBP . 12 Based on a randomised , controlled trial , human albumin ( 1.5g / kg at diagnosis and 1g / kg on day 3 ) is recommended in patients with SBP , as the combination of human albumin and cefotaxime reduced the incidence of renal dysfunction and mortality ( from 29 % to 10 %) compared with cefotaxime alone . 13 Table 1 summarises some of the main studies and interventions used .
Patients with cirrhosis can display a distinct presentation , namely hepatorenal syndrome ( HRS )– acute kidney injury , which is characterised by the lack of response to plasma volume expansion with human albumin , absence of shock , and no evidence of parenchymal disease . 21 Delay in the administration of appropriate antibiotics leads to worse outcomes in these patients . Patients with infection should also receive albumin , not only for its oncotic effects , but also for its antioxidant , scavenging and endothelial stabilisation functions . Once HRS – acute kidney injury is diagnosed , human albumin administration should be started in addition to terlipressin and continued until a total or partial response or for a maximum of 2 weeks . Although the optimal human albumin dose is not fully established , the recommended dose is 20 – 40g / day . 14 Central venous pressure monitoring can help to optimise human albumin dose and prevent circulatory overload . 13
There is evidence that long-term albumin administration in patients with decompensated cirrhosis reduces 18-month mortality and incidence of complications and hospitalisations , is effective in the management of ascites , is cost-effective and has a good safety profile . 22 Therefore , it could be included in the treatment options for patients with cirrhosis and ascites before liver transplantation . Albumin as a replacement fluid has been a matter of debate . In some centres , a large amount of albumin is exogenously administered following the transplantation to support circulatory stability . Beneficial properties were attributed to albumin in recent studies , whereas postoperative hypoalbuminaemia has been linked to the development of acute kidney injury . During liver transplantation , there is a translocation of albumin , probably to the interstitial space , which persists until the third postoperative day and for which a role has not been clarified . Certain centres choose to replace two-thirds of the required fluids with crystalloids and onethird of drain losses with albumin . 23 Potential diuretic-induced side effects , such as hyponatraemia and hyperkalaemia , were also lessened , whereas gastroesophageal variceal bleeding was unchanged . Besides these clinical effects , long-term albumin administration also led to a significant reduction in the need of patient hospitalisations and the number of days spent in hospital .
Conclusion Liver transplant recipients are prone to hypoalbuminaemia , and liver transplant patients with hypoalbuminaemia have an increased risk of postoperative complications . A routine of generous perioperative administration of exogenous albumin during liver transplantation , which maintains plasma albumin concentration from 2.5 – 3.0g / dl , might reduce the haemodynamic support required and plays a very important role in preventing some of the complications in these patients .
References 1 Wiedermann C . Albumin – Indications and clinical benefits . HPE Handbook – Human Albumin 2019 ; 12 – 15 . 2 Bartoletti M et al . Epidemiology and outcomes of bloodstream infection in patients with cirrhosis . J Hepatol 2014 ; 61:51 – 8 . 3 Fernández J , Bert F , Nicolas-Chanoine MH . The challenges of multi-drugresistance in hepatology . J Hepatol 2016 ; 65:1043 – 54 . 4 Brown ML , Fong Y , Helton WS . Pre- and postoperative nutrition in hepatobiliary surgery . Surg Liver Biliary Tract 2012 ; 531 – 44 . 5 Amouzandeh M , Novak G , Norberg A . Albumin mass balance and kinetics in liver transplantation . Crit Care 2018 ; 22:152 . 6 Hiroi K et al . Postoperative course of serum albumin levels and organ dysfunction after liver transplantation . Transplant Proc 2019 ; 51:2750 – 4 . 7 Hai LT et al . Outcome and progress
of organ transplantation in Vietnam . Military Med J 2019 ; 12 – 15 . 8 Gatta A , Verardo A , Bolognesi M . Hypoalbuminemia . Intern Emerg Med 2012 ; 7 ( Suppl . 3 ): S193e9 . 9 Warty V et al . Distribution of FK 506 in plasma lipoproteins in transplant patients . Transplant Proc 1991 ; 23:954 . 10 Trull A et al . Influence of albumin supplementation on tacrolimus and cyclosporine therapy early after liver transplantation . Liver Transpl 2002 ; 8:224 . 11 Bernardi M et al . Mechanisms of decompensation and organ failure in cirrhosis : From peripheral arterial vasodilation to systemic inflammation hypothesis . J Hepatol 2015 ; 63:1272 – 84 . 12 Fernandez J et al . Bacterial infections in cirrhosis : Epidemiological changes with invasive procedures and norfloxacin prophylaxis . Hepatology 2002 ; 35:140 – 8 . 13 European Association for the Study of the Liver ( EASL ) Clinical practice guidelines for the management of
patients with decompensated cirrhosis . J Hepatol 2018 ; 69:406 – 60 . 14 Ortega R et al . Terlipressin therapy with and without albumin for patients with hepatorenal syndrome : Results of a prospective , nonrandomized study . Hepatology 2002 ; 36:941 – 8 . 15 Ito D et al . Behavior and clinical impact of ascites after living donor liver transplantation : risk factors associated with massive ascites . J Hepatobiliary Pancreat Sci 2016 ; 23:688e96 . 16 Ertmer C et al . Impact of human albumin infusion on organ function in orthotopic liver transplantation – retrospective matched-pair analysis . Clin Transplant 2015 ; 29:67e75 . 17 Zoellner H et al . Inhibition of microvascular endothelial apoptosis in tissue explants by serum albumin . Microvasc Res 1999 ; 57:162e73 18 Hye-Won J et al . Early postoperative hypoalbuminaemia is associated with pleural effusion after donor hepatectomy : A propensity score analysis
of 2316 donors . Sci Rep 2019 ; 9 ( 1 ): 2790 . 19 Yamada Y et al . Clinical implications of pleural efusion in patients with acute type B aortic dissection . Eur Heart J Acute Cardiovasc Care 2016 ; 5:72 – 81 . 20 Puchalski JT et al . Etiologies of bilateral pleural effusions . Respir Med 2013 ; 107:284 – 91 . 21 Angeli P et al . Diagnosis and management of acute kidney injury in patients with cirrhosis : Revised consensus recommendations of the International Club of Ascites . J Hepatol 2015 ; 62:968 – 74 . 22 Caraceni P et al . Long-term albumin administration in decompensated cirrhosis ( ANSWER ): An open-label randomised trial . Lancet 2018 ; 391:2417 – 29 . 23 Piano S et al . The empirical antibiotic treatment of nosocomial spontaneous bacterial peritonitis : Results of a randomized , controlled clinical trial . Hepatology 2016 ; 63:1299 – 309 .
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