Comparison of outcome in patients with cirrhosis and ascites following treatment with albumin or a synthetic colloid: a randomised controlled pilot trail

Use of albumin: an update

Human albumin (HA) is widely used for volume replacement or correction of hypoalbuminaemia. The value of HA in the clinical setting continues to be controversial, and it is unclear whether in today's climate of cost consciousness, there is still a place for such a highly priced substance. It is therefore appropriate to update our knowledge of the value of HA. With the exception of women in early pregnancy, there appears to be few indications for the use of HA to correct hypovolaemia. Some studies of traumatic brain injury and intensive care patients suggest negative effects on outcome and organ function of (hyperoncotic) HA. Modern synthetic colloids appear to be a cheaper alternative for maintaining colloid oncotic pressure. The value of using HA to correct hypoalbuminaemia has not been clearly justified. Theoretical and pharmacological benefits of HA, such as oxygen radical scavenging or binding of toxic substances, have not as yet been shown to have beneficial clinical consequences. Experimental data from cell lines or animals do not appear to mimic the clinical setting. Convincing data justifying the use of HA either for treating hypovolaemia or for correcting hypoalbuminaemia are still lacking. A restricted use of HA is recommended.

Ascites and spontaneous bacterial peritonitis: an Asian perspective

Ascites is the most common complication of liver cirrhosis, and it develops as a consequence of portal hypertension and splanchnic vasodilatation. Depending on severity, management of ascites consists of diverse strategy, including dietary sodium restriction, diuretic therapy, repeated large-volume paracentesis with albumin infusion, transjugular intrahepatic portosystemic shunt, and liver transplantation. Recently, advances in medical therapy have been made with satavaptan, a V2 receptor antagonist, vasoconstrictors, such as clonidine, midodrine, or terlipressin, and other categories of drugs, including docarpamine and Chinese herbs. These drugs may serve as useful adjuncts to conventional diuretics in the management of ascites. Besides ascites itself, serious complications, such as spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome, frequently ensue in decompensated cirrhosis. SBP develops from the translocation of bacteria from the intestine, and successful management with early diagnosis and treatment with proper prevention in patients of high risk is necessary. In summary, ascites is a starting point for more serious complications in liver cirrhosis. Although liver transplantation is the fundamental treatment, it is not always feasible, and consequently various means of treatment should be used. Further study, particularly in Asia where hepatitis B virus-related cirrhosis is predominant, is warranted to improve the clinical outcome.

Rationale for albumin infusions

PURPOSE OF REVIEW

To describe the metabolism and function of albumin, and to scrutinize the evidence that infusion of albumin may be beneficial in disease. To explain why albumin infusion does not improve clinical outcome in most disease states, studied.

RECENT FINDINGS

Albumin acts as a binding protein and an oncotic agent. However, albumin may also act as an extracellular scavenger, which leads to oxidation of albumin. It is likely that this compromises its function and it is possible that this drives its degradation. In disease, these useful processes are accelerated leading to rapid ageing of the molecule.Albumin infusion does not improve clinical outcome despite increasing oncotic pressure in chronic disease. It is not superior to nonprotein colloids or electrolyte solutions in acute hypovolemia with one or two exceptions (liver failure, possibly cerebral infarction). One potential explanation is that pharmaceutical albumin does not have the oxidative qualities that freshly synthesized albumin has.

SUMMARY

Albumin infusion has not proven to achieve clinical benefit in many acute and chronic disease states with a few exceptions in acute hypovolemia (e.g. postparacentesis). Future studies should reveal whether infusion of freshly synthesized nonoxidized albumin is of greater clinical benefit.

Evaluation and management of patients with refractory ascites

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis (LVP) and transjugular intrahepatic portasystemic stent-shunt (TIPS) are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morbidity and mortality (most surgical options) rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.

Pathogenetic background for treatment of ascites and hepatorenal syndrome

Ascites and hepatorenal syndrome (HRS) are the major and challenging complications of cirrhosis and portal hypertension that significantly affect the course of the disease. Liver insufficiency, portal hypertension, arterial vasodilatation, and systemic cardiovascular dysfunction are major pathophysiological hallmarks. Modern treatment of ascites is based on this recognition and includes modest salt restriction and stepwise diuretic therapy with spironolactone and loop diuretics. Tense and refractory ascites should be treated with a large volume paracentesis, followed by volume expansion or transjugular intrahepatic portosystemic shunt. New treatment strategies include the use of vasopressin V(2)-receptor antagonists and vasoconstrictors. The HRS denotes a functional and reversible impairment of renal function in patients with severe cirrhosis with a poor prognosis. Attempts of treatment should seek to improve liver function, ameliorate arterial hypotension and central hypovolemia, and reduce renal vasoconstriction. Ample treatment of ascites and HRS is important to improve the quality of life and prevent further complications, but since treatment of fluid retention does not significantly improve survival, these patients should always be considered for liver transplantation.

[Comparative study of hospital costs associated with human albumin 20% (Vialebex 20%) or polygeline as a fluid resuscitation strategy for cirrhotic ascites]

OBJECTIVES

To compare the hospital costs associated with two fluid resuscitation strategies for cirrhotic ascites: one with human albumin 20% (Vialebex 20%) and one with polygeline.

METHODS

Multicenter prospective randomized double-blinded comparative trial (that also compared efficacy and tolerance). The economic evaluation was based on direct medical costs throughout the follow-up period: days of hospitalization, hospital consultations, medical procedures, and fluid resuscitation products. This cost-minimization study had a 6-month follow-up period. Daily costs in euros were adjusted over a 30-day period. The study was interrupted prematurely because of an alert due to the bovine origin of the polygeline, and the inclusion objectives could therefore not be met.

RESULTS

The economic analysis included all patients in the efficacy population (group receiving human albumin 20%: n=30, polygeline group: n=38). It found a standardized cost per patient for 30 days of treatment that was significantly lower (p=0.004) for human albumin 20% (median: 1915 euro; range: 1330-4105) than for polygeline (median: 4612 euro; range: 2138-12234). This difference is related mainly to a reduction in the frequency and duration of hospitalization in specialized units, but also to other aspects of management: hospitalization in other departments, specific solutions for the study products, and hospital procedures.

CONCLUSION

The economic results of this trial favor a fluid resuscitation strategy that uses human albumin 20% for cirrhotic patients. They are consistent with the clinical results and help assess the cost-benefit ratio of human albumin 20% for this indication.

Drug insight: the role of albumin in the management of chronic liver disease

Albumin is the most abundant protein in the circulation. Its main physiologic function is to maintain colloid osmotic pressure. Better understanding of albumin's other physiologic functions has expanded its application beyond maintenance of intravascular volume. In patients with cirrhosis, albumin has been used as an adjunct to diuretics to improve the diuretic response. It has also been used to prevent circulatory dysfunction developing after large-volume paracentesis. Newer indications in cirrhotic patients include preventing hepatorenal syndrome in those with spontaneous bacterial peritonitis, and treating established hepatorenal syndrome in conjunction with vasoconstrictor therapies. The use of albumin for many of these indications is controversial, mostly because of the paucity of well-designed, randomized, controlled trials. The cost of albumin infusions, lack of clear-cut benefits for survival, and fear of transmitting unknown viruses add to the controversy. The latest indication for albumin use in cirrhotic patients is extracorporeal albumin dialysis, which has shown promise for the treatment of hepatic encephalopathy; its role in hepatorenal syndrome or acute on chronic liver failure has not been established. Efforts should be made to define the indications for albumin use, dose of albumin required and predictors of response, so that patients gain the maximum benefit from its administration.

Diagnosis and treatment of acute renal failure in patients with cirrhosis

In patients with cirrhosis, acute renal failure is due to prerenal failure (a result of decreased renal perfusion) and tubular necrosis. There are 3 main causes of prerenal failure: 'true hypovolemia' (which complicates hemorrhage, gastrointestinal or renal fluid losses), sepsis, and type 1 hepatorenal syndrome (HRS). Prerenal failure may also be due to the administration of non-steroidal antiinflammatory drugs, or intravascular radiocontrast agents. Prerenal failure is reversible after restoration of renal blood flow. Treatments target the cause of hypoperfusion, and fluid replacement is used to treat 'non-HRS' prerenal failure. In patients with type 1 HRS with very low short-term survival rate, liver transplantation is the ideal treatment. Systemic vasoconstrictor therapy with terlipressin (combined with intravenous human albumin), noradrenaline (combined with albumin and furosemide) or midodrine (combined with octreotide and albumin) may improve renal function in patients with type 1 HRS waiting for liver transplantation. MARS (for Molecular Adsorbent Recirculating System) and the transjugular intrahepatic portosystemic shunt may also improve renal function in these patients. In patients with cirrhosis, acute tubular necrosis is mainly due to an ischemic insult to the renal tubules. Studies are needed on the natural course and treatment (e.g., renal-replacement therapy) of acute tubular necrosis in patients with cirrhosis.

Management of ascites and hepatic hydrothorax

The natural course of patients with cirrhosis is frequently complicated by the accumulation of fluid in the peritoneal or pleural cavities and interstitial tissue. Functional renal abnormalities that occur as a consequence of decreased effective arterial blood volume are responsible for fluid accumulation in the form of ascites and hepatic hydrothorax. Ascites is the most common complication of cirrhosis and poses an increased risk for infections, renal failure and mortality. Patients have a poor prognosis and it is estimated that nearly half will die in approximately 2 years without liver transplantation. Hepatic hydrothorax is defined as a pleural effusion greater than 500 mL (mostly right-sided) in patients with cirrhosis without cardiopulmonary disease; the estimated prevalence is approximately 5-10%. Liver transplantation is the most definitive cure for both conditions in those patients that are suitable candidates. However, the mainstay of therapy for minimizing fluid accumulation in both conditions includes sodium restriction and administration of diuretics. This article reviews the most current concepts of pathogenesis, clinical findings, diagnosis, and treatment of these complications of cirrhosis.