Albumin for cirrhosis‐related complications

Abstract

What is known and objective The purpose of this paper was to discuss the limitations of the studies serving as the evidence for recommendations in clinical practice guidelines concerning albumin use for cirrhosis‐related complications, review relevant studies published since the guidelines and suggest directions for future investigations. Comment There are no recent comprehensive clinical practice guidelines concerning albumin. Instead, more recent albumin guidelines reflect areas of specialty practice such as those by American and European associations for the study of the liver and liver disease. Studies published since the guidelines are useful for helping to define the most appropriate indications for albumin with respect to cirrhosis‐related complications, as well as directions for future research. What is new and conclusion Albumin has a long history of attempts to define appropriate uses by meta‐analysis, but given the high cost and episodic shortages of albumin, there is a need for adequately powered randomized controlled trials using current state‐of‐the‐art care evaluating the use of albumin to prevent or treat cirrhosis‐related complications.

Expert perspectives for the pharmacist on facilitating and improving the use of albumin in cirrhosis

“…Although overarching clinical practice guidance and guidelines on HSA use are lacking, specialty practice guidelines are available. 42 While many uses of HSA are considered “inappropriate” and may need to be curbed, the most current and well-established indications for the use of HSA in cirrhosis pertain to conditions characterized by an acute worsening of effective hypovolemia, 17 such as ascites, PPCD, SBP, and HRS-AKI. 9 As such, pharmacists can ensure that these indications are added as “appropriate” on any institutional guidelines that are developed and become familiar with the situations listed in Table 2 where HSA administration may provide benefit.…”

“…The literature indicates that the high cost and periodic shortages with HSA have made its appropriate use a long-standing subject of debate. 42 Inappropriate use for noncirrhosis indications also clouds the picture of when HSA should be used. The AASLD has acknowledged that the dosing recommendations put forth in its guidance are somewhat nonspecific because of a lack of high-quality studies in patients with conditions associated with cirrhosis.…”

“…Recently published studies have examined HSA use outside of its current indications, specifically, the efficacy of long-term HSA administration in less acutely ill patients outside hospital settings to modify the natural history of cirrhosis and prevent disease progression. 42 The ANSWER study is an Italian multicenter, randomized, open-label study examining a population of 431 patients with noncomplicated but persistent ascites despite diuretic administration. The patients were randomized to receive standard medical treatment (SMT) or SMT plus HSA (40 g twice a week for 2 weeks and then 40 g per week) for 18 months.…”