Use of albumin infusion for cirrhosis-related complications: An international position statement

Zhaohui Bai^{1

2}, Nahum Méndez-Sánchez³, Fernando Gomes Romeiro⁴, Andrea Mancuso⁵, Cyriac Abby Philips⁶, Frank Tacke⁷, Metin Basaranoglu⁸, Massimo Primignani⁹, Mostafa Ibrahim¹⁰, Yu Jun Wong¹¹, Filipe Gaio Nery¹², Rolf Teschke¹³, Carlos Noronha Ferreira¹⁴, Alberto E Muñoz¹⁵, Kanokwan Pinyopornpanish¹⁶, Thierry Thevenot¹⁷, Shivaram Prasad Singh¹⁸, Arpan Mohanty¹⁹, Sanjaya K Satapathy²⁰, Lorenzo Ridola²¹, Hitoshi Maruyama²², Evangelos Cholongitas²³, Giovanni Battista Levi Sandri²⁴, Li Yang²⁵, Shalimar²⁶, Yongping Yang²⁷, Erica Villa²⁸, Aleksander Krag²⁹, Florence Wong³⁰, Rajiv Jalan³¹, Alastair O'Brien³², Mauro Bernardi³³, Xingshun Qi^{1

2}; Liver Cirrhosis-related Complications (LCC)-International Special Interest Group

Affiliations

¹ Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China.
² Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China.
³ Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico.
⁴ Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil.
⁵ Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy.
⁶ Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India.
⁷ Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany.
⁸ Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey.
⁹ Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
¹⁰ Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt.
¹¹ Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.
¹² Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal.
¹³ Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany.
¹⁴ Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.
¹⁵ Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina.
¹⁶ Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
¹⁷ Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d'Hépatologie et de Soins Intensifs Digestifs, Besançon, France.
¹⁸ Kalinga Gastroenterology Foundation, Odisha, India.
¹⁹ Section of Gastroenterology, Boston Medical Center, Boston, MA, USA.
²⁰ Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA.
²¹ Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy.
²² Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan.
²³ First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
²⁴ Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy.
²⁵ Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China.
²⁶ Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
²⁷ Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China.
²⁸ Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy.
²⁹ Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
³⁰ Department of Medicine, University of Toronto, Toronto, ON, Canada.
³¹ Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK.
³² Division of Medicine, Royal Free Campus, London, UK.
³³ Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.

PMID: 37456673
PMCID: PMC10339261
DOI: 10.1016/j.jhepr.2023.100785

Use of albumin infusion for cirrhosis-related complications: An international position statement

Zhaohui Bai et al. JHEP Rep. 2023.

. 2023 May 5;5(8):100785.

doi: 10.1016/j.jhepr.2023.100785. eCollection 2023 Aug.

Authors

Affiliations

¹ Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China.
² Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China.
³ Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico.
⁴ Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil.
⁵ Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy.
⁶ Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India.
⁷ Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany.
⁸ Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey.
⁹ Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
¹⁰ Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt.
¹¹ Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.
¹² Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal.
¹³ Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany.
¹⁴ Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.
¹⁵ Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina.
¹⁶ Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
¹⁷ Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d'Hépatologie et de Soins Intensifs Digestifs, Besançon, France.
¹⁸ Kalinga Gastroenterology Foundation, Odisha, India.
¹⁹ Section of Gastroenterology, Boston Medical Center, Boston, MA, USA.
²⁰ Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA.
²¹ Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy.
²² Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan.
²³ First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
²⁴ Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy.
²⁵ Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China.
²⁶ Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
²⁷ Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China.
²⁸ Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy.
²⁹ Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
³⁰ Department of Medicine, University of Toronto, Toronto, ON, Canada.
³¹ Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK.
³² Division of Medicine, Royal Free Campus, London, UK.
³³ Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.

PMID: 37456673
PMCID: PMC10339261
DOI: 10.1016/j.jhepr.2023.100785

Abstract

Background & aims: Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy.

Methods: Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications.

Results: Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion.

Conclusions: Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated.

Impact and implications: Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.

Keywords: Decompensated; Human albumin; Kidney injury; Liver failure; Management; Portal hypertension; Sepsis.

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Conflict of interest statement

ZB, NM-S, FGR, AM, and CAP declare no potential conflicts of interest that pertain to this work. FT’s laboratory received research grants from Gilead, Allergan, Bristol-Myers Squibb and Inventiva. MB, MP, MI, YJW, FGN, RT, CNF, AEM, KP, TT, and SPS declared no potential conflicts of interest concerning the publication of this article. AM received grant funding from Gilead (clinical trials), Inventiva, Intercept, and Novo-Nordisk; and was a member of the advisory board (Gilead). SKS received research funding from Novartis, Durect, Fibronostics, and Gilead. LR, HM, EC, GBLS, LY, S, YY, EV, and AK declared no potential conflicts of interest concerning the publication of this article. FW received grant support from Grifols. RJ is the inventor of OPA, which has been patented by UCL and licensed to Mallinckrodt Pharma. He is also the founder of Yaqrit Discovery, a spin-off company from University College London, Hepyx Limited, and Cyberliver. He has research collaborations with Yaqrit Discovery, has received speaker fees from Grifols, and is a consultant for Ambys, Takeda, and Bioconvergent Health. AOB declared no potential conflicts of interest concerning the publication of this article. MB declared the following potential conflicts of interest with respect to the publication of this article: personal fees from CLS Behring GmbH (consultant, speaker), Grifols SA (consultant, speaker), Takeda (consultant, speaker), PPTA (speaker), and Octapharma (speaker). XQ declared no potential conflicts of interest concerning the publication of this article. He received a governmental grant from the Young and Middle-aged Scientific and Technological Innovation Talents Support Plan Project of Shenyang (RC210011), which does not influence the publication of this article, for holding the final advisory meeting of the position statement. Please refer to the accompanying ICMJE disclosure forms for further details.

Figures

**Fig. 1**
The flowchart of the Delphi process used in this study.

See this image and copyright information in PMC

Comment in

Albumin use in cirrhosis: a nephrology viewpoint on key considerations and cautionary notes.
Koratala A, Kazory A. Koratala A, et al. Hepatobiliary Surg Nutr. 2024 Jun 1;13(3):536-539. doi: 10.21037/hbsn-24-220. Epub 2024 May 17. Hepatobiliary Surg Nutr. 2024. PMID: 38911218 Free PMC article. No abstract available.

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Use of albumin infusion for cirrhosis-related complications: An international position statement

Affiliations

Use of albumin infusion for cirrhosis-related complications: An international position statement

Authors

Affiliations

Abstract

Conflict of interest statement

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