AISF-SIMTI position paper: the appropriate use of albumin in patients with liver cirrhosis

Treatment of COVID-19 in Hemodialysis Patients Using Traditional Chinese Medicine: A Single-Center, Retrospective Study

Background: To explore the effect of combining traditional Chinese medicine (TCM) and Western medicine in hemodialysis patients with coronavirus disease 2019 (COVID-19).

Methods: This study was conducted from 27 January 2020 to 17 March 2020 in Wuhan Third Hospital Guanggu Branch, Wuhan, China. Fifty-three patients were included and divided into a control group (CG), which received Western medicine and a combined treatment group, which received TCM and Western medicine (TG). Clinical and laboratory data, TCM symptom scores, and chest computed tomography results were extracted and compared between the two groups.

Results: The TG included 21 (67.7%) men and 10 (32.3%) women with a mean age of 61.02 (standard deviation [SD] 15.07, range 26–89) years. The mean dialysis duration in the TG was 49 (SD 31) months. Of all patients in the TG, 27 (87.1%) had fatigue, 18 (58.1%) had dry cough, 16 (51.6%) had anorexia, 11 (35.5%) had dyspnea, and 11 (35.5%) had fever. The CG included 14 (63.6%) men and 8 (36.4%) women with a mean age of 61.45 (SD 13.78, range 36–84) years. The mean dialysis duration in the CG was 63 (SD 46) months. Of all patients in the CG, 21 (95.5%) had fatigue, 12 (54.5%) had dry cough, 17 (77.3%) had anorexia, 12 (54.5%) had dyspnea, and 7 (31.8%) had fever. After treatment, the TCM symptom scores of the two groups decreased; the anorexia scores were lower in the TG than in the CG (p < 0.05). After treatment, albumin increased and D-dimer, C-reactive protein, and lactate dehydrogenase levels decreased in the TG. The d-dimer levels were lower and the albumin level was higher in the TG than in the CG after treatment (p < 0.05). The cure rate was higher, and the mortality rate was lower in the TG than in the CG (p < 0.05).

Conclusion: A combination of TCM and Western medicine in hemodialysis patients with COVID-19 could relieve symptoms and help recovery. Further evidence from larger randomized controlled trials is needed to confirm our results.

[Use of albumin : State of the art]

The Saline versus Albumin Fluid Evaluation (SAFE) study has demonstrated that the use of albumin as an infusion solution in volume therapy can be regarded as safe. An exception is hypo-oncotic albumin in traumatic brain injury. While clear indications of albumin exist for some patients with liver cirrhosis, large studies that demonstrate a clinically relevant advantage beyond hemodynamic effects and would therefore justify wider use in many other areas are still lacking. In large-volume paracentesis, spontaneous bacterial peritonitis, but also in hepatorenal syndrome, use of albumin is recommended and established due to clinical benefit in randomized controlled trials. In septic shock, use of albumin may be considered, with two large studies addressing this issue in Germany and Italy being still in the recruitment phase. For volume therapy, albumin can be used primarily when other measures for hemodynamic stabilization have been exhausted. This applies to volume resuscitation in hypovolemia as well as in conservative fluid management in the so-called "de-resuscitation" phase. The extent to which the correction of severe hypoalbuminemia with exogenous albumin can improve the impaired outcome of these patients is also part of ongoing studies. On the way to a more individualized medicine, hypoalbuminemia may serve as a parameter in future decision making for or against the use of albumin in volume therapy.

Single-center analysis of the inappropriate use of human albumin and nutritional support in hospitalized patients with hypoproteinemia in China

BACKGROUND

This study used single-center analysis of human serum albumin clinical usage and enteral-parenteral nutritional support to establish clinical application standards for the rational use of human serum albumin.

METHODS

A total of 1984 patients receiving human serum albumin were enrolled in this retrospective study to analyze the rational application of human serum albumin and enteral-parenteral nutritional support.

RESULTS

Among 1984 patients, 1044 (52.6%) were found to have irrational applications for human serum albumin use. Major indications for irrational applications were hypoproteinemia (30.0%) and nutritional support (21.9%). Surgical departments including thoracic surgery, orthopedics, and neurosurgery had the most irrational applications, occupying 18.4%, 8.4%, and 4.2%, respectively. A total of 1627 patients (82%) required nutritional support and 745 (45.8%) had irrational nutritional support. Moreover, 694 patients (35.0%) received human serum albumin as the only source of nutritional support.

CONCLUSIONS

Clinical training and the establishment of an approval system should be used to enhance the rational use of human serum albumin, ensuring medication safety, reducing medical costs, and avoiding the waste of medical resources.

Albumin Administration is Efficacious in the Management of Patients with Cirrhosis: A Systematic Review of the Literature

The use of albumin in patients with cirrhosis has been extensively discussed over recent years. Current treatment approaches depend on targeting related complications, aiming to treat and/or prevent circulatory dysfunction, bacterial infections and multi-organ failure. Albumin has been shown to prolong survival and reduce complications in patients with cirrhosis. This review aims to ascertain whether the use of albumin is justified in patients with cirrhosis. A systematic review of randomized controlled trials (RCTs) and meta-analyses evaluating albumin use in patients with cirrhosis published between 1985 and February 2020 was conducted; the quality and risk of bias of the included studies were assessed. In total, 45 RCTs and 10 meta-analyses were included. Based on the included evidence, albumin is superior at preventing and controlling the incidence of cirrhosis complications vs other plasma expanders. Recent studies reported that long-term albumin administration to patients with decompensated cirrhosis improves survival with a 38% reduction in the mortality hazard ratio compared with standard medical treatment alone. Albumin infusions are justified for routine use in patients with cirrhosis, and the use of albumin either alone or in combination with other treatments leads to clinical benefits. Long-term administration of albumin should be considered in some patients.

Hemodynamic and Systemic Effects of Albumin in Patients with Advanced Liver Disease

Purpose of Review

Albumin administration is recommended to prevent or treat specific complications of decompensated cirrhosis based on its capacity to expand plasma volume. However, the molecule also has many other biological properties that are unrelated to the oncotic activity. The purpose of this review is to examine the hemodynamic and systemic effects of albumin administration in patients with decompensated cirrhosis.

Recent Findings

Besides plasma expansion, albumin appears to act against inflammation, facilitate immunocompetence, and improve cardiac and endothelial function, thus antagonizing critical steps in the pathophysiological cascade underlying decompensated cirrhosis.

Summary

Increasing knowledge of the pathophysiological mechanisms of the disease, as well the pleiotropic properties of the molecule, provides the rationale for considering albumin as a multi-target disease-modifying agent in decompensated cirrhosis. Both oncotic and non-oncotic properties likely concur with the clinical benefits of long-term albumin administration recently demonstrated in these patients.

The cost-effectiveness of albumin in the treatment of decompensated cirrhosis in Germany, Italy, and Spain

BACKGROUND

Albumin is frequently prescribed in cirrhotic patients with acute decompensation. However, the true cost effectiveness of albumin use in cirrhotic patients is still under debate.

OBJECTIVE

To evaluate the cost-effectiveness of albumin in the treatment of decompensated cirrhosis in Germany, Italy, and Spain.

METHODS

A decision-tree economic model was developed to evaluate treatments for decompensated cirrhosis from the hospital perspective over a typical inpatient admission. The treatments for large volume paracentesis (LVP) were albumin vs saline, gelatin, or no fluid. The treatments for spontaneous bacterial peritonitis (SBP) were albumin plus antibiotics vs antibiotics alone. The treatments for hepatorenal syndrome (HRS) were albumin plus a vasoconstrictor vs a vasoconstrictor alone. Effectiveness inputs were literature-based. Cost inputs included pharmacy costs and medical complication costs of decompensated cirrhosis. The primary model assessments were incremental cost-effectiveness ratios (ICERs) per life saved and per quality-adjusted life-year (QALY).

RESULTS

Albumin was found to be both less costly and more effective relative to saline, gelatin, and no fluid for the treatment of LVP across all 3 countries. For SBP, albumin plus antibiotics was more clinically effective than antibiotics alone in all 3 countries. The combination of albumin plus antibiotics was less costly than antibiotics alone in Germany and Italy, making albumin a dominant treatment (ie, less costly and more effective). In the management of SBP in Spain, albumin plus antibiotics compared to antibiotics alone resulted in ICERs of €1516 per life saved and €3369 per QALY gained. Albumin plus a vasoconstrictor was both less costly and more effective than vasoconstrictor alone in the treatment of HRS across all 3 countries.

CONCLUSION

This analysis demonstrates that albumin is cost-effective in terms of lives saved and QALYs gained in the management of decompensated cirrhosis associated with LVP, SBP, or HRS.