As a hospital pharmacist, you’ll be asked about the role of IV albumin in patients hospitalized with acute decompensated liver disease. New evidence shows that giving these patients DAILY albumin to raise and maintain levels above 3 g/dL does NOT reduce infection, kidney dysfunction, or death. Plus albumin may increase pulmonary edema risk, and It is also expensive.
Continue to avoid routine use of albumin in stable floor patients admitted with new or worsening ascites, hepatic encephalopathy or a suspected variceal bleed. But some patients with acute decompensated liver disease may still need albumin. For example, use albumin to prevent central volume depletion in those undergoing large-volume paracentesis, removing over 5 liter. And give albumin for spontaneous bacterial peritonitis IF there’s a risk of renal dysfunction (BUN over 30 mg/dL, serum creatinine above 1 mg/dL, or total bilirubin over 4 mg/dL).
Also continue to think of albumin to resuscitate a septic shock patient who isn’t responding to adequate crystalloids. Create an order set with indications to help with albumin dosing. For example, give 1.5 g/kg, then 1 g/kg two days later for spontaneous bacterial peritonitis. But for shock, use 12.5 g to 25 g boluses until mean arterial pressure and other markers improve. When giving albumin in liver disease, generally use the 20% or 25% product. Its oncotic pressure draws fluid into the intravascular space. Typically max the 25% albumin rate at 2 mL/min for nonemergent use, to limit fluid overload. Monitor for respiratory distress, hypertension, etc (especially with heart failure or other risks).
REFERENCES
China L, Freemantle N, Forrest E, Kallis Y, Ryder SD, Wright G, Portal AJ, Becares Salles N, Gilroy DW, O'Brien A; ATTIRE Trial Investigators. A Randomized Trial of Albumin Infusions in Hospitalized Patients with Cirrhosis. N Engl J Med. 2021 Mar 4;384(9):808-817. Available at: https://www.nejm.org/doi/10.1056/NEJMoa2022166
Runyon BA; AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013 Apr;57(4):1651-3. Available at: https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.26359
Marquez V. Albumin infusions and decompensated cirrhosis: No longer the elixir of life. Canadian Liver Journal, pp. – June 09, 202. Available at: https://canlivj.utpjournals.press/doi/pdf/10.3138/canlivj-2021-0009