The Use of Albumin in Liver Cirrhosis - Current Treatment Concepts and Future Outlook

Albumin is one of the most used human products worldwide. It is produced in the liver and has multiple functions all over the body. Therefore, if the liver is diseased albumin synthesis and quality declines. It is intuitive to say that if there is a deficiency we can supply - however this is not as easy as it appears. Use of albumin in patients with liver disease has been studied over the last decades with recent studies widening our understanding of this drug. This book focuses on the use of abdomen and liver cirrhosis, the mechanisms and part of physiology behind it as well as the dos and don'ts of clinical practice and current guidelines. Worldwide experts of liver cirrhosis and use of albumin have contributed to the book and reflected the current recommendations.

1.Introduction12 2.The Pathogenesis and Clinical Course of Cirrhosis16 2.1.Liver fibrosis16 2.2.Portal hypertension17 2.3.Liver cirrhosis and decompensation17 2.4.Diagnostic options20 2.5.Treatment options21 3.Properties of Endogenous Albumin in Cirrhosis26 3.1.Human albumin – synthesis, metabolism, structure and properties26 3.1.1.Albumin synthesis and metabolism26 3.1.2.Albumin structure26 3.1.3.Albumin functions26 3.2.Pathomechanisms and complications in cirrhosis29 3.2.1.Portal hypertension29 3.2.2.Acute decompensation and acute-on-chronic liver failure30 3.3.Serum albumin abnormalities in cirrhosis31 3.3.1.Hypoalbuminemia31 3.3.2.Albumin structure and function abnormalities in cirrhosis31 3.3.3.Effective albumin concentration32 4.Treatment Concepts and Established Indications36 4.1.Historical overview of indications for human albumin in cirrhosis36 4.2.Albumin use after large-volume paracentesis36 4.2.1.Large volume paracentesis and post-paracentesis circulatory dysfunction36 4.2.2.Albumin use for the prevention of PPCD after LVP37 4.2.3.Is there a role for albumin in paracentesis of less than 5 liters?38 4.3.Albumin use in patients with spontaneous bacterial peritonitis38 4.3.1.Prognostic significance of bacterial infections in cirrhosis38 4.3.2.Pathophysiology and the clinical course of spontaneous bacterial peritonitis39 4.3.3.Albumin use for prevention of acute kidney injury in patients with spontaneous bacterial peritonitis39 4.3.4.Do all patients with spontaneous bacterial peritonitis require albumin?40 4.4.Albumin for the management of patients with cirrhosis and acute kidney injury40 4.4.1.Redefining acute kidney injury in cirrhosis40 4.4.2.Use of albumin in the diagnostic work-up of AKI42 4.4.3.Albumin in the treatment of HRS-AKI44 4.4.4.Adverse events associated with albumin use in patients with AKI44 5.New indications for albumin in patients with decompensated cirrhosis52 5.1.Acute or short-term albumin administration52 5.1.1.Bacterial infections unrelated to SBP53 5.1.2.Sepsis with hypotension54 5.1.3.Hepatic encephalopathy55 5.1.4.Hyponatremia56 5.1.5.Acute decompensation of cirrhosis requiring hospitalization57 5.1.6.Considerations for acute and short-term albumin treatment58 5.2.Long-term use of albumin for the management of ascites58 5.2.1.The ANSWER study58 5.2.2.The “refractory ascites” study60 5.2.3.The MACHT study60 5.2.4.The “filling the gap” hypothesis61 5.2.5.Real-word experience61 5.2.6.Considerations for long-term albumin treatment62 6.Role of Albumin Levels, Biomarkers and Treatment Monitoring66 6.1.Changes in quantity and quality of albumin in decompensated cirrhosis66 6.2.Treatment targets in acute and long-term settings67 6.2.1.Acute setting67 6.2.2.Long-term setting69 6.3.Future directions and conclusions70 7.The Caveats of Albumin Use in Cirrhosis74 7.1.Volume expanding effects of albumin and the risk of volume overload74 7.2.Volume expanding effects of albumin and the risk for variceal hemorrhage76 7.3.Albumin effects on coagulation78 7.4.Allergic reaction to albumin78 7.5.Other possible side effects81 8.Mechanisms of Albumin86 8.1.Mechanisms of action of albumin and pathophysiologic considerations in cirrhosis86 8.2.Oncotic pressure86 8.3.Antioxidant and binding abilities87 8.4.Endothelial stabilization and coagulation87 8.5.Anti-inflammatory88 9.Future Directions92 9.1.Choose wisely92 9.2.Albumin levels and biomarkers for guidance92 9.3.Drugs bound to albumin93 9.4.Organization of services93 Index94