Albumin Infusion in Patients Undergoing Large-Volume Paracentesis. Does it work?

Use of albumin in patients with large volume paracentesis:

Guidelines suggest giving albumin 6-8 g/L for large volume paracentesis (>5L). Does giving albumin provide benefit over its high cost?

This meta-analysis included 17 trials (see graph below). The main exclusion criteria for the RCTs are:

  • Renal dysfunction and gastrointestinal bleeding were study-exclusion criteria in all 17 trials.
    – However, in six trials, at least some degree of renal dysfunction was present at baseline in 9.7%-35.1% of patients.
  • Infection, including spontaneous bacterial peritonitis and sepsis, in 16 trials
  • Liver cancer in 14
  • Hepatic encephalopathy in 13
  • Low prothrombin activity percentage (<25%-40%) or prolonged prothrombin time in 11
  • Thrombocytopenia (<30,000-50,000 mm3) in 10
  • Marked hyperbilirubinemia (>5-10 mgdL1) in 8
  • Severe hyponatremia (<120-125 mEqL1) in 4

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So the trials only included patients with tense ascites without other co-morbid conditions (no infections, no/minimal renal failure, no malignancy, no hepatic encephalopathy, no bleeding tendency).

Mean Child-Pugh score was reported for 11 trials, and values ranged from 8.8 to 11.0 (moderate-severe cirrhosis).

Intervention:

  • Diuretics were discontinued before study treatment in 16 trials, whereas in the remaining trial, the prestudy diuretic regimen could be continued without change.
  • Total paracentesis was performed in 13 trials and repeated LVP in three. Type of paracentesis was unspecified for one trial. The mean volume of ascites fluid removed during paracentesis ranged from 5.5 to 15.9 L.
  • In 12 trials, albumin was administered at a dose of 8 g/L ascites fluid removed. The dose in two trials was 6 g/L, and in one trial each 5 g/L, 10 g/L and, depending on ascites volume removed, 7-10 gL/L. The concentration of albumin infused was 20% in 12 trials, 25% in one trial, and unspecified in four trials.

Outcomes:

  • Length of follow-up was reported for eight trials. Median follow-up for those eight trials was 76 days.
  • Mortality, PCD and hyponatremia as endpoints.

4  5

6

Clearly can see that

  • The main benefit of albumin infusion in LVP is lesser case of PCD (postparacentesis circulatory dysfunction).
  • There is only modest benefit in mortality improvement in albumin infusion group,
  • Albumin infusion also helps to reduce hypoNa in patients requiring LVP compared with other volume expanders and no treatment.

Conclusion:

  • For patients requiring LVP (>5 L), albumin infusion 6-8 g/L reduces the risk of PCD.
  • However, need to remember that most of the trials only include stable cirrhotic patients (no hepatic encephalopathy, no bleeding tendency, no infection, no liver malignancy, no renal failure). In reality, many cirrhotic patients have at least one of the exclusion criteria used in the trials. Further RCTs need to be done to assess the benefit (or no benefit) of albumin infusion in this group of patients.

Reference

Mauro Bernardi, Paolo Caraceni, Roberta J. Navickis, and Mahlon M. Wilkes. Albumin Infusion in Patients Undergoing Large-Volume Paracentesis: A Meta-Analysis of Randomized Trials. HEPATOLOGY, 2012;55(4):1172-81

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