Albumin Infusion Research Articles

Safety and efficacy of cell-free and concentrated ascites reinfusion therapy against cirrhotic ascites in comparison with malignancy-related ascites.

Cell-free and concentrated ascites reinfusion therapy (CART) has been performed against cirrhotic ascites, one of the most common complications seen in patients with decompensated cirrhosis. The aim of this study is to investigate its safety and efficacy, and differences in clinical profiles from CART against malignancy-related ascites with different pathological background. The present investigation involved a sub-analysis of data obtained from a prospective observational study of CART performed at 22 centers. The condition of each procedure, therapeutic options, laboratory data, performance status, dietary intake, and abdominal circumference of participants were analyzed. Clinical parameters were compared between before and after CART, with or without albumin infusion, and also primary diseases including cirrhosis and malignant disease. Between January 2014 and January 2015, a total of 48 and 275 CART procedures were performed in patients with cirrhosis and malignancies. In cirrhotic patients, serum albumin concentration increased significantly in groups both with and without concomitant albumin infusion (P=0.002 and P=0.023), and no significant difference in CART interval was seen between these groups (P=0.393). CART interval was not significantly different between cirrhosis and malignancy groups (P=0.334). Dietary intake significantly improved after CART in both groups (P=0.043 and P<0.001). Adverse events were with no clinical significance as observed in patients with malignancies. Cell-free and concentrated ascites reinfusion therapy was performed safely and effectively in patients with ascites related to decompensated cirrhosis and offers the potential efficacy to maintain plasma colloid osmotic pressure after paracentesis as well as in patients with malignancy.

Postoperative 20% albumin vs standard care and acute kidney injury after high-risk cardiac surgery (ALBICS): study protocol for a randomised trial

BackgroundAcute kidney injury (AKI) is a common complication of cardiac surgery. Factors such as cardiopulmonary bypass, aortic cross-clamping and surgical stress may precipitate renal hypoperfusion and ischaemia, inflammation and oxidative stress are associated with development of AKI. Albumin’s pharmacological properties and widespread availability have the potential to mitigate these factors. However, the effect of albumin on cardiac surgery-associated AKI is unknown.ObjectiveTo evaluate the impact of postoperative 20% albumin infusion on kidney function after high-risk cardiac surgery.MethodsWe designed an open-label, multicentre, randomised controlled trial—the ALBICS study (ALBumin Infusion and acute kidney injury following Cardiac Surgery). A total of 590 patients undergoing high-risk cardiac surgery (combined procedure or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) will be enrolled into the study and randomly allocated to receive a postoperative 20% albumin infusion or standard care in a 1:1 ratio, stratified by centre and baseline renal function. The study fluid will be administered upon arrival in intensive care for 15 h. Patients will be followed up until 28 days after surgery or until discharge from the hospital. The primary outcome is the proportion of patients who develop AKI in both groups. Secondary outcomes to be measured are proportions of AKI stage II and III, 28-day mortality, mechanical ventilation time and length of stay in intensive care and hospital.ConclusionThis trial aims to determine if a postoperative infusion of concentrated albumin reduces the risk of AKI following high-risk cardiac surgery.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12619001355167. Registered on 03 October 2019—retrospectively registered. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378383.

Acute kidney injury in Enhanced Recovery After Surgery (ERAS) protocols in open gynecologic oncology surgery

<h3>Objectives:</h3> To estimate the incidence of and factors associated with acute kidney injury (AKI) in women undergoing elective open gynecologic oncology surgery using an Enhanced Recovery After Surgery (ERAS) protocol. <h3>Methods:</h3> A retrospective cohort study was performed. All women who underwent open gynecologic surgery for suspected or confirmed malignancy using an ERAS protocol between March 2018 to December 2019 were identified. Incidence and degree of AKI were classified by the Kidney Disease Improving Global Outcomes (KDIGO) staging system. Descriptive statistics and univariate analysis for associated factors were performed using Fisher's exact test. <h3>Results:</h3> A total of 114 patients met inclusion criteria. The majority underwent abdominal hysterectomy (102/114, 89%) with anesthesia time ≥240 minutes in 73% of patients. Median age and body mass index (BMI) were 54 years and 28.1 kg/m², respectively. A total of 9 patients (9/114, 7.9%) developed KDIGO class 1 (7/114, 6.1%) or class 2 (2/114, 1.8%) AKI. All but one case of AKI (8/9, 88.8%) resolved by day of discharge. Factors associated with AKI included: obesity (OR 13.8, p=0.003), ASA 3+ (OR 11.8, p=0.01), complication other than AKI (OR 9.3, p=0.02), cardiovascular disease (OR 8.3, p=0.03) diabetes mellitus (OR 4.7, p=0.04), and baseline creatinine of ≥1.0 (OR 9.3, p=0.04). Procedural blood loss, age >65, ECOG performance status, receipt of neoadjuvant chemotherapy, intraoperative time, intraoperative albumin infusion, and postoperative transfusion were not significantly associated with AKI. <h3>Conclusions:</h3> AKI is uncommon in women undergoing open gynecology oncology surgery using an ERAS protocol. Nearly all cases resolved prior to discharge and were associated with patient-specific factors. While care should be taken during protocol implementation to monitor for and to prevent AKI, fluid restriction principles used in ERAS protocols are safe in this study population.

In decompensated cirrhosis, targeted albumin infusions did not improve an in-hospital composite outcome at 15 d.

China L, Freemantle N, Forrest E, et al. A randomized trial of albumin infusions in hospitalized patients with cirrhosis. N Engl J Med. 2021;384:808-17. 33657293.

Expert consensus on the use of human serum albumin in critically ill patients.

Expert consensus on the use of human serum albumin in critically ill patients.

Severe hypercalcemia associated with hypophosphatemia in very premature infants: a case report

BackgroundSevere hypercalcemia is rare in newborns; even though often asymptomatic, it may have important sequelae. Hypophosphatemia can occur in infants experiencing intrauterine malnutrition, sepsis and early high-energy parenteral nutrition (PN) and can cause severe hypercalcemia through an unknown mechanism. Monitoring and supplementation of phosphate (PO4) and calcium (Ca) in the first week of life in preterm infants are still debated.Case presentationWe report on a female baby born at 29 weeks’ gestation with intrauterine growth retardation (IUGR) experiencing sustained severe hypercalcemia (up to 24 mg/dl corrected Ca) due to hypophosphatemia while on phosphorus-free PN. Hypercalcemia did not improve after hyperhydration and furosemide but responded to infusion of PO4. Eventually, the infant experienced symptomatic hypocalcaemia (ionized Ca 3.4 mg/dl), likely exacerbated by contemporary infusion of albumin. Subsequently, a normalization of both parathyroid hormone (PTH) and alkaline phosphatase (ALP) was observed.ConclusionsAlthough severe hypercalcemia is extremely rare in neonates, clinicians should be aware of the possible occurrence of this life-threatening condition in infants with or at risk to develop hypophosphatemia. Hypophosphatemic hypercalcemia can only be managed with infusion of PO4, with strict monitoring of Ca and PO4 concentrations.

Overview of Albumin Physiology and its Role in Pediatric Diseases.

Albumin plays a critical role in a wide range of disease processes; however, the role of albumin in pediatric patients has not been well described. This article aims to review albumin physiology and kinetics in children, albumin's impact on pediatric diseases, and the utility of albumin as a predictor of clinical outcome. Hypoalbuminemia is seen in a wide range of conditions, including protein-losing enteropathy, hepatic synthetic failure, malnutrition, inflammatory states, and renal disease. While the impact of hypoalbuminemia has been more extensively studied in adult patients, there is a relative paucity of literature in the pediatric population. Hypoalbuminemia is a marker of poor outcome in critically ill children and those undergoing a wide range of medical interventions. Albumin infusions may be an effective therapy for fluid resuscitation and for patients with severe hypoalbuminemia.

Albumin Infusion in Critically Ill COVID-19 Patients: Hemodilution and Anticoagulation.

Hypercoagulation is one of the major risk factors for ICU treatment, mechanical ventilation, and death in critically ill patients infected with SARS-CoV-2. At the same time, hypoalbuminemia is one risk factor in such patients, independent of age and comorbidities. Especially in patients with severe SARS-CoV-2-infection, albumin infusion may be essential to improve hemodynamics and to reduce the plasma level of the main marker of thromboembolism, namely, the D-dimer plasma level, as suggested by a recent report. Albumin is responsible for 80% of the oncotic pressure in the vessels. This is necessary to keep enough water within the systemic circulatory system and for the maintenance of sufficient blood pressure, as well as for sufficient blood supply for vital organs like the brain, lungs, heart, and kidney. The liver reacts to a decrease in oncotic pressure with an increase in albumin synthesis. This is normally possible through the use of amino acids from the proteins introduced with the nutrients reaching the portal blood. If these are not sufficiently provided with the diet, amino acids are delivered to the liver from muscular proteins by systemic circulation. The liver is also the source of coagulation proteins, such as fibrinogen, fibronectin, and most of the v WF VIII, which are physiological components of the extracellular matrix of the vessel wall. While albumin is the main negative acute-phase protein, fibrinogen, fibronectin, and v WF VIII are positive acute-phase proteins. Acute illnesses cause the activation of defense mechanisms (acute-phase reaction) that may lead to an increase of fibrinolysis and an increase of plasma level of fibrinogen breakdown products, mainly fibrin and D-dimer. The measurement of the plasma level of the D-dimer has been used as a marker for venous thromboembolism, where a fourfold increase of the D-dimer plasma level was used as a negative prognostic marker in critically ill SARS-CoV-2 hospitalized patients. Increased fibrinolysis can take place in ischemic peripheral sites, where the mentioned coagulation proteins can become part of the provisional clot (e.g., in the lungs). Although critically ill SARS-CoV-2-infected patients are considered septic shock patients, albumin infusions have not been considered for hemodynamic resuscitation and as anticoagulants. The role of coagulation factors as provisional components of the extracellular matrix in case of generalized peripheral ischemia due to hypoalbuminemia and hypovolemia is discussed in this review.

Can primary palliative care education change life-sustaining treatment intensity of older adults at the end of life? A retrospective study

BackgroundPalliative care education has been carried out in some hospitals and palliative care has gradually developed in mainland China. However, the clinical research is sparse and whether primary palliative care education influence treatment intensity of dying older adults is still unknown. This study aims to explore the changes to the intensity of end-of-life care in hospitalized older adults before and after the implementation of primary palliative care education.MethodsA retrospective study was conducted. Two hundred three decedents were included from Beijing Tongren Hospital’s department of geriatrics between January 1, 2014 to December 31, 2019. Patients were split into two cohorts with regards to the start of palliative care education. Patient demographics and clinical characteristics as well as analgesia use, medical resources use and provision of life-sustaining treatments were compared. We used a chi-square test to compare categorical variables, a t test to compare continuous variables with normal distributions and a Mann–Whitney U test for continuous variables with skewed distributions.ResultsOf the total participants in the study, 157(77.3%) patients were male. The median age was 88 (interquartile range; Q1-Q3 83–93) and the majority of patients (N = 172, 84.7%) aged 80 years or older. The top 3 causes of death were malignant solid tumor (N = 74, 36.5%), infectious disease (N = 74, 36.5%), and cardiovascular disease (N = 23, 11.3%). Approximately two thirds died of non-cancer diseases. There was no significant difference in age, gender, cause of death and functional status between the two groups (p > 0.05). After primary palliative care education, pain controlling drugs were used more (p < 0.05), fewer patients received electric defibrillation, bag mask ventilation and vasopressors (p < 0.05). There was no change in the length of hospitalization, intensive care admissions, polypharmacy, use of broad-spectrum antibiotics, blood infusions, albumin infusions, nasogastric/nasoenteric tubes, parenteral nutrition, renal replacement and mechanical ventilation (p > 0.05).ConclusionsPrimary palliative care education may promotes pain controlling drug use and DNR implementation. More efforts should be put on education about symptom assessment, prognostication, advance care planning, code status discussion in order to reduce acute medical care resource use and apply life-sustaining treatment appropriately.

Effect of albumin administration on post-operation mortality, duration on ventilator, and hospital stay on patients in cardiac intensive care: An observational study

Purpose: To justify the use of albumin infusion in patients in post-surgery cardiac intensive care unit.&#x0D; Methods: All patients who were hemodynamically stable before the operation and admitted into the surgical intensive care unit following coronary artery bypass, cardiopulmonary bypass, or aortic surgery, had no excessive postoperative bleeding and not on diuretic treatment, were included in the analysis. A total of 1998 patients were divided into two cohorts, viz, the first group was placed on albumin infusion (n = 999) while the second group received normal saline infusion (n = 999). Data were obtained from DICOM files of patients and records of pharmacy. Wilcoxon test or two-tailed paired t-test followed by Tukey post-hoc tests were performed for statistical analysis at 95 % of confidence level.&#x0D; Results: Albumin and normal saline administration did not decrease the duration of mechanical ventilation, incidence of mechanical ventilation, need for blood transfusion, and length of hospital stay (p &gt; 0.05). Albumin infusion decreased the need for fresh frozen plasma transfusion from 85 to 67, reduced mortality (p = 0.0005, q = 3.959), lowered serum lactate level (p &lt; 0.0001, q = 43.853), but increased cardiac index (p &lt; 0.0001, q = 12.192) as well as financial burden (p &lt; 0.0001, q = 95.158) for the patients, compared to normal saline group.&#x0D; Conclusion: In view of the foregoing, it is recommended that the use of restriction of albumin resuscitation in surgical intensive care unit should be restricted in this subset of patients evluated in this study.

Low Serum Albumin Predicts Severe Outcomes in COVID-19 Infection: A Single-Center Retrospective Case-Control Study

Background: Coronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection. Methods: We included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes. Results: The mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an inverse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 - 24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 - 37.14, P < 0.05). Conclusions: Low serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated. J Clin Med Res. 2021;13(5):258-267 doi: https://doi.org/10.14740/jocmr4507

Midodrine and albumin versus albumin alone for the secondary prophylaxis of acute kidney injury in a patient with cirrhosis and ascites.

Acute kidney injury (AKI) in a patient with cirrhosis has high short-term mortality. Midodrine has shown promising results in the treatment of AKI-hepatorenal syndrome (HRS-AKI). To compare midodrine and albumin versus albumin alone for the secondary prophylaxis of HRS-AKI. Open labeled, nonrandomized, pilot study. Patients with a diagnosis of HRS-AKI were recruited after complete recovery. Patients were given midodrine daily (15 mg) and injection albumin infusion 20 g weekly in group-A (Gp-A) and injection albumin 20 g weekly with no midodrine in group-B (Gp-B). The primary endpoint was the recurrence of AKI-HRS, and the secondary endpoint was ascites tap in 2-month period. A total of 42 patients were enrolled in Gp-A, n = 22, and Gp-B, n = 20. There was no significant difference between the groups (Gp-A vs. Gp-B) in terms of age, model stage liver disease, Child-Turcotte-Pugh score and serum creatinine at inclusion (1.27 ± 0.1 vs. 1.22 ± 0.2 mg/dL). During follow up ten patients (50%) in Gp-B and four patients (18%) in Gp-A develop HRS-AKI (P = 0.04). The mean number of ascites tap was significantly higher in Gp-B compared to Gp-A (2.6 ± 0.5 vs. 1.9 ± 0.5) in 2 months. There was a significant increase in mean arterial pressure in Gp-A compared to Gp-B on days 7, 15, 30, 45 and 60. There was a significant difference in mean arterial pressure at day 7 in patients who developed HRS-AKI versus those who did not develop HRS-AKI [(n = 14, 65.5 ± 5.5) vs. (n = 28,74.6 ± 9.2 mm Hg), P = 0.02]. Midodrine along with albumin infusion, is helpful in the secondary prophylaxis of HRS-AKI and reduces the number of ascites tap. However, a large randomized study is required for further validation.

Albumin therapy for acute ischemic stroke: a meta-analysis.

Human serum albumin has shown remarkable efficacy in rodent models of ischemic stroke, while results from relevant clinical research on albumin therapy remain controversial. We conducted a meta-analysis of published studies to quantitatively analyze the neurofunctional outcomes of patients with ischemic stroke treated with albumin. PubMed, Embase, and Cochrane Library were searched in July 2020. A total of four studies and 1611 patients were included. The aggregated results indicated that there were 635 patients with good neurological outcomes, among which 321 patients were in the albumin group (39.8%) and 314 patients in the control group (39.1%), showing no statistically significant difference between the albumin and control groups (OR = 1.04, 95% CI 0.85-1.27). The results suggest that albumin therapy at the acute stage of ischemic stroke has no beneficial effect on the long-term neurological function of patients with ischemic stroke. Considering pulmonary edema and other complications are more likely to occur in such patients after albumin infusion, the administration of albumin therapy for acute ischemic stroke should be done with utmost caution.

Refractory Postsurgical Hypothyroidism in Nephrotic Syndrome

Abstract 62-year-old female with a history of thyroid cancer of unknown type s/p thyroidectomy 30 years prior to presentation, who had 2 months of worsening generalized edema and increasing need of dose escalation of her oral thyroid replacement by her PCP. Despite increasing her thyroxine dose multiple times and adding Armour thyroid based on increasing TSH and decreasing FT4 on outpatient labs, her edema continued to get worse. She presented to the Emergency Department. She takes no other medications. Symptoms include malaise, cold intolerance, weight gain, hair loss, bloating without constipation,“feeling foggy” and that her memory seemed a bit “off”, and she felt her mood was more “sensitive”, and she had atypical non-exertional chest discomfort. On exam she was was bradycardic to 56 and hypertensive to 175 systolic, had faint bibasilar crackles were present bilaterally, had significant pitting edema of the bilateral lower extremities, 3+ up to the level of her abdomen, as well as pitting edema of her bilateral upper extremities, and no periorbital edema was seen. Her neurologic exam was non-focal. Outpatient labs included TSH 178, free T4 0.35, albumin 1.2, and BNP level of 57. Her liver and kidney function tests were normal. Hospital labs included a normal CBC, chemistry with an albumin of 2.2 and normal range liver and kidney function. Thyroid function tests included a very high TSH level of 141, low free T4 level of 0.37, and a free T3 toward the lower end of normal. Lipid panel showed severe hypercholesterolemia. Urine studies showed microhematuria as well as the equivalent of proteinuria to the level of 10 grams per day. HIV was negative and complement levels were within normal limits. CXR, renal US, transvaginal US, and CT chest/abdomen/pelvis were performed to investigate the proteinuria and potential secondary causes of the proteinuria, all of which were unremarkable for acute or pertinent findings. Pathology results from a kidney biopsy showed membranous nephropathy. The patient initially received IV steroids and IV thyroxine as well as an albumin infusion. She was quickly transitioned to oral thyroxine due to her stability on presentation. She was given a statin and ACE inhibitor as well as IV Lasix. And she was discharged on thyroxine, with Armour thyroid being discontinued. She had severe hypothyroidism in a patient dependent on exogenous thyroid hormone which was exacerbated by severe proteinuria due to a new-onset nephrotic syndrome. Her hospital course uneventful. She responded well to intravenous diuretics. After her diagnosis of membranous nephropathy, Nephrology recommended continued conservative treatment due to her normal renal function and improving edema with outpatient follow up. She only received a single dose of IV thyroxine and remained stable after switching to oral thyroxine.

Low Serum Albumin Predicts Severe Outcomes in COVID-19 Infection: A Single-Center Retrospective Case-Control Study.

BackgroundCoronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection.MethodsWe included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes.ResultsThe mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an inverse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 - 24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 - 37.14, P < 0.05).ConclusionsLow serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated.

Long-term albumin infusion in decompensated cirrhosis: A review of current literature.

Decompensated cirrhosis is characterized by chronic inflammation and severe portal hypertension leading to systemic circulatory dysfunction. Albumin infusion has been widely used in decompensated cirrhosis in patients with spontaneous bacterial peritonitis, large-volume paracentesis and hepatorenal syndrome. Emerging data suggest long-term albumin infusion has both oncotic and non-oncotic properties which may improve the clinical outcomes in decompensated cirrhosis patients. We review the current literature on both the established and potential role of albumin, and specifically address the controversies of long-term albumin infusion in decompensated cirrhosis patients.

Transjugular Portosystemic Shunting in Refractory Cirrhotic Ascites

Aim. Improvement of refractory ascites (RA) outcomes in underlying cirrhotic portal hypertension (PH) through optimising the transjugular intrahepatic portosystemic shunting (TIPS) procedure among therapy measures.Materials and methods. The survey included 107 patients with RA admitted to portal hypertension units of the Rostov State Medical University Surgical Clinic during 2007—2020. The patients were randomly assigned to two cohorts similar by gender, age, cirrhosis aetiology and condition severity. The control cohort had conventional paracentesis and albumin infusion. In cohort 2, 57 patients had minimally invasive endovascular TIPS surgery in a recommended setting.Results. TIPS eliminated PH in all 57 patients of cohort 2. Cohort 1 was reported with progressive esophagogastric varices (EGV), their enlargement in 37 and rupture in 11 patients during the first 12 months. Cohort 2 revealed the grade 3—2 and 2—1 EGV reduction in 24 (41.1%) patients with shunt surgery and in 39 (68.4%) patients in one year. Esophagogastric variceal bleeding (EGVB) developed in 9 patients in cohort 1, with 7 lethal outcomes. No variceal bleeding was observed in cohort 2, with 7 patients having the portosystemic shunt dysfunction.Conclusion. The TIPS procedure is justified in cirrhotic PH patients with RA for reducing the mortality rate in a one year follow-up.

Intravenous albumin for spontaneous bacterial peritonitis and renal dysfunction in patients with cirrhosis-short review

Current clinical guidelines for albumin use in decompensated cirrhosis recommend the use of intravenous albumin infusions for management of ascites-related symptoms and paracentesis (removal of ascitic fluid) and for the management of spontaneous bacterial peritonitis (SBP), renal dysfunction and variceal bleeding. Routine albumin use is not recommended for the management of non-SBP infections. The aim of this review is to improve our understanding of the effects of albumin use in cirrhosis by reviewing the currently available and quantifying the effectiveness of intravenous albumin therapy to prevent specific cirrhosis complications, spontaneous bacterial peritonitis (SBP) and renal dysfunction. Long-term albumin administration to patients with decompensated cirrhosis improves survival, prevents complications, eases the management of ascites and reduces hospitalizations, thus being cost-effective. However, variant results indicate that further investigations are needed, aiming at confirming the beneficial effects of albumin, clarifying its optimal dosage and administration schedule and identify patients who would benefit most from long-term albumin administration.

A Randomized Trial of Albumin Infusions in Hospitalized Patients with Cirrhosis

BackgroundInfection and increased systemic inflammation cause organ dysfunction and death in patients with decompensated cirrhosis. Preclinical studies provide support for an antiinflammatory role of albumin, but confirmatory large-scale clinical trials are lacking. Whether targeting a serum albumin level of 30 g per liter or greater in these patients with repeated daily infusions of 20% human albumin solution, as compared with standard care, would reduce the incidences of infection, kidney dysfunction, and death is unknown.MethodsWe conducted a randomized, multicenter, open-label, parallel-group trial involving hospitalized patients with decompensated cirrhosis who had a serum albumin level of less than 30 g per liter at enrollment. Patients were randomly assigned to receive either targeted 20% human albumin solution for up to 14 days or until discharge, whichever came first, or standard care. Treatment commenced within 3 days after admission. The composite primary end point was new infection, kidney dysfunction, or death between days 3 and 15 after the initiation of treatment.ResultsA total of 777 patients underwent randomization, and alcohol was reported to be a cause of cirrhosis in most of these patients. A median total infusion of albumin of 200 g (interquartile range, 140 to 280) per patient was administered to the targeted albumin group (increasing the albumin level to ≥30 g per liter), as compared with a median of 20 g (interquartile range, 0 to 120) per patient administered to the standard-care group (adjusted mean difference, 143 g; 95% confidence interval [CI], 127 to 158.2). The percentage of patients with a primary end-point event did not differ significantly between the targeted albumin group (113 of 380 patients [29.7%]) and the standard-care group (120 of 397 patients [30.2%]) (adjusted odds ratio, 0.98; 95% CI, 0.71 to 1.33; P=0.87). A time-to-event analysis in which data were censored at the time of discharge or at day 15 also showed no significant between-group difference (hazard ratio, 1.04; 95% CI, 0.81 to 1.35). More severe or life-threatening serious adverse events occurred in the albumin group than in the standard-care group.ConclusionsIn patients hospitalized with decompensated cirrhosis, albumin infusions to increase the albumin level to a target of 30 g per liter or more was not more beneficial than the current standard care in the United Kingdom. (Funded by the Health Innovation Challenge Fund; ATTIRE EudraCT number, 2014-002300-24; ISRCT number, N14174793.)

Tolvaptan reduces the required amount of albumin infusion in patients with decompensated cirrhosis with uncontrolled ascites : a multicenter retrospective propensity score-matched cohort study

Background : The aim of this retrospective study was to determine whether tolvaptan treatment reduces the amount of albumin administered, volume of ascites removed, and frequency of paracentesis procedures in patients with decompensated cirrhosis with uncontrolled ascites with conventional diuretics. Patients and methods : The control (C) group included patients treated with conventional diuretics. The tolvaptan (T) group included patients treated with both tolvaptan and conventional diuretics. Both groups were matched according to baseline parameters. The amount of albumin administered, volume of ascites removed, and frequency of paracentesis within 30 days of onset of uncontrolled ascites were compared between the two groups. Results : After matching, 74 patients (C=37, T=37) were included. Baseline parameters (C vs. T group) were as follows : age, 69.5 ± 9.3 vs. 70.4 ± 11.0 years (p = 0.702) ; males, 24 (64.9%) vs. 25 (67.6%) (p = 0.999) ; patients with hepatocellular carcinoma, 17 (45.9%) vs. 18 (48.6%) (p = 0.999) ; serum albumin levels at treatment initiation, 2.76 ± 0.48 vs. 2.73 ± 0.49 g/dL (p = 0.773), and serum creatinine levels at treatment initiation, 1.18 ± 1.23 vs. 1.09 ± 0.48 g/dL (p = 0.679). In the C vs. T groups, respectively, mean amount of albumin administered was 51.0 ± 31.4 vs. 33.4 ± 29.8 g/month (p = 0.016) ; mean volume of ascites removed was 2,905 ± 4,921 vs. 1,824 ± 3,185 mL/month (p = 0.266) ; and mean frequency of paracentesis was 0.92 ± 1.46 vs. 0.89 ± 1.45 procedures (p = 0.937). Conclusions : Tolvaptan reduced the use of albumin infusion in patients with decompensated cirrhosis and was effective and acceptable for uncontrolled ascites.