NEJM Journal Watch
Daniel D. Dressler, MD, MSc, MHM, FACP, reviewing
A randomized trial demonstrated no benefit.
Guidelines recommend intravenous (IV) albumin for patients with cirrhosis after large-volume paracentesis and for patients with spontaneous bacterial peritonitis or hepatorenal syndrome (Hepatology 2013; 57:165). In vitro data suggest albumin’s anti-inflammatory effects might ameliorate inflammation, infection, or kidney injury in patients with cirrhosis. British investigators randomized 777 patients with low serum albumin levels (i.e., <3 g/dL) who were admitted for decompensated cirrhosis (i.e., new or worsening ascites, encephalopathy, or variceal bleeding) to receive either standard care or daily IV albumin infusions (20% human albumin at 100–400 mL daily; titrated, based on serum albumin level, to a goal of 3.5 g/dL, for as long as 14 days or until hospital discharge).
In intent-to-treat analysis, researchers found no significant difference between the albumin group and the standard-care group for the composite endpoint of infection, kidney dysfunction, or inpatient death (30% in each group), nor did they find any differences in individual outcomes within the composite endpoint. Mortality at 1, 3, and 6 months was similar in the two groups, but more patients in the albumin group developed pulmonary edema or fluid overload (6% vs. 2%).
Most patients in this study had alcohol as the etiology of cirrhosis, leaving open the question whether these results apply to cirrhosis from other etiologies. Nevertheless, the findings demonstrate clearly that IV albumin infusions — a very high–cost intervention — has no benefit in patients with decompensated cirrhosis and should not be employed outside of other guideline-recommended usages.