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. 2021 May;133(9-10):421-431.
doi: 10.1007/s00508-020-01769-9. Epub 2020 Dec 3.

Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria

Nikolaus Pfisterer  1   2   3 , Caroline Schmidbauer  1   2   4 , Florian Riedl  5 , Andreas Maieron  5 , Vanessa Stadlbauer  6 , Barbara Hennlich  3 , Remy Schwarzer  1   2 , Andreas Puespoek  7 , Theresa Bucsics  1   2 , Maria Effenberger  8 , Simona Bota  9 , Michael Gschwantler  4   10 , Markus Peck-Radosavljevic  9 , Mattias Mandorfer  1   2 , Christian Madl  3   10 , Michael Trauner  1 , Thomas Reiberger  11   12   13
Affiliations

Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria

Nikolaus Pfisterer et al. Wien Klin Wochenschr. 2021 May.

Abstract

Background: Portal hypertension (PH) causes severe complications in patients with liver cirrhosis, such as variceal bleeding and ascites; however, data on the knowledge and perceptions on guideline recommendations for the management of varices and the use of albumin is scarce.

Methods: We designed two structured surveys on (i) the management of varices and (ii) the use of albumin for Austrian physicians of specialized Gastro-Intestinal (GI) centers. The interviewed physicians were confronted spontaneously and provided ad hoc responses to the questionnaire.

Results: In total, 158 surveys were completed. Interestingly, many specialists (30%) would recommend a follow-up gastroscopy after 1 year in patients with compensated cirrhosis without varices (i.e., overtreatment). For small varices, 81.5% would use non-selective beta blockers (NSBB) for primary prophylaxis (PP). For PP in patients with large varices, endoscopic band ligation (EBL) plus NSBB was preferred by 51.4% (i.e., overtreatment). Knowledge on the indication criteria for early TIPS (transjugular intrahepatic portosystemic shunt) was reported by 54.3%, but only 20% could report these criteria correctly. The majority (87.1%) correctly indicated a preference to use NSBB and EBL for secondary prophylaxis (SP). The majority of participating gastroenterologists reported no restrictions on the use of albumin (89.8%) in their hospitals. Of the interviewed specialists, 63.6% would use albumin in patients with SBP; however, only 11.4% would use the doses recommended by guidelines. The majority of specialists indicated using albumin at the recommended doses for hepatorenal syndrome (HRS-AKI, 86.4%) and for large volume paracentesis (LVP, 73.3%). The individual responses regarding albumin use for infections/sepsis, hyponatremia, renal impairment, and encephalopathy were heterogeneous.

Conclusion: The reported management of PH and varices is mostly adherent to guidelines, but endoscopic surveillance in patients without varices is too intense and EBL is overused in the setting of PP. Knowledge on the correct use of early TIPS must be improved among Austrian specialists. Albumin use is widely unrestricted in Austria; however, albumin is often underdosed in established indications.

Keywords: Albumin; Non-selective beta blockers; Practice; Survey; Transjugular intrahepatic portosystemic shunt.

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Conflict of interest statement

N. Pfisterer received travel support from Abbvie and MSD. M. Mandorfer has served as a speaker and/or consultant and/or advisory board member for AbbVie, Bristol-Myers Squibb, Gilead, Janssen and W. L. Gore & Associates and has received a research award from Medis. C. Schmidbauer received travel support von Gebro, Gilead und Abbvie. M. Peck-Radosavljevic has served as a speaker for CSL Behring. T. Reiberger received travel support from Boehringer-Ingelheim, W.L. Gore & Associates, Gilead, Roche and MSD; grant support from Abbvie, Boehringer-Ingelheim, Gilead, W.L. Gore & Associates, Phenex Pharmaceuticals and Philipps; served on advisory boards for Abbvie, Bayer, Boehringer-Ingelheim, Gilead and MSD; and received lecture fees from Boehringer-Ingelheim, Gore, MSD and Roche. All authors declare that they have no conflicts of interests in regard to this study.

Figures

Fig. 1
Fig. 1
Flow chart depicting information on participating doctors. Q Question
Fig. 2
Fig. 2
Geographical distribution of returned questionnaires across Austria. n number of questionnaires, HA survey about the use of albumin in patients with portal hypertension, PHT survey about the management and prevention of variceal bleeding and other complication of portal hypertension. Source of the map of Austria: https://d-maps.com/m/europa/austria/autriche_de/autriche_de46.pdf
Fig. 3
Fig. 3
Responses given to questions regarding the management of varices and variceal bleeding in survey‑A to questions with a strong recommendations by guidelines and b weak recommendations by guidelines. c Responses on the preferred choice for primary bleeding prophylaxis in patients with compensated liver cirrhosis (Child-Pugh Class A6) with large varices and red spot signs. d Responses on the preferred choice for secondary prophylaxis of variceal bleeding. Q question, n/a not answered, n number of surveys, NSBB nonselective beta blockers, TIPS transjugular intrahepatic portosystemic shunt, EBL endoscopic band ligation, AVB acute variceal bleeding, PP primary prophylaxis, SP secondary prophylaxis, CI contraindication
Fig. 4
Fig. 4
Responses of survey‑B on albumin use in patients with liver cirrhosis with a strong recommendations and b weak recommendations/controversial recommendations. Responses on use of albumin in c patients with paracentesis of a volume of 5L ascitic fluid and in d patients with spontaneous bacterial peritonitis. Q question, n/a not answered, n number of surveys, n/a not answered, SBP spontaneous bacterial peritonitis, BW body weight, AKI acute kidney injury, HRS hepatorenal syndrome
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