Variations in albumin use in patients with cirrhosis: An AASLD members survey

Potential conflict of interest: Dr. O'Leary consults for Grifols. Dr. Bajaj received grants from Grifols. Dr. Wong received grants from Grifols. To the Editor: The quantitative and qualitative impacts of hypoalbuminemia are critically important in patients with cirrhosis.1 Therefore, to evaluate the practice patterns regarding ascites management and albumin use, a brief electronic survey was sent to 757 US‐based clinical American Association for the Study of Liver Diseases (AASLD) members, which resulted in a 30% (n = 225) response rate: 77% were hepatologists at transplant centers, 13% were hepatologists at nontransplant centers, and 10% were gastroenterologists. The majority (82%) were in academic centers, followed by community hospitals (13%) and Veterans Affairs hospitals (8%). Most respondents saw six to 25 (27%), 26‐75 (37%), and >75 (33%) patients with cirrhosis/month. Approximately half of the respondents had more than seven patients requiring paracentesis/month, while 33% had three to six patients/month requiring paracentesis. Interestingly, interventional radiology performed the majority of paracenteses in outpatients (56%) and slightly fewer in inpatients (45%). Most practitioners (72%) were satisfied with the paracentesis done outside their supervision. Simulated Cases Case 1 A patient with cirrhosis recently discharged after a >5‐L paracentesis 1 week prior returns with tense ascites, with an international normalized ratio of 2 and a platelet count of 35,000. The majority would have interventional radiology (43%), or their midlevel practitioners (32%) perform the paracentesis. Only 12% would limit the fluid tapped to 2‐5 L. Almost all (98%) would administer intravenous (IV) albumin (66% during and 31% after the procedure), while only 8% and 14% would administer fresh frozen plasma or platelets, respectively. Case 2 An inpatient was admitted with refractory ascites, spontaneous bacterial peritonitis (SBP), and creatinine of 1 mg/dL. Most respondents would administer IV albumin (93%) and IV antibiotics (95%), while 14% would also administer diuretics. The patient developed a 0.3‐mg/dL creatinine increase over 24 hours without intravascular depletion. 66% would hold diuretics, 68% would administer IV albumin, while 14% would not change management. The patient developed tense ascites 3 days later; respondents were split between performing <5‐L (38%) and >5‐L (49%) paracentesis with IV albumin regardless of the volume removed. Albumin Use There was considerable variation in the reasons for albumin use: 91% for hepatorenal syndrome (HRS), 90% for SBP, 24% for infections other than SBP, 57% for hypotension, 31% for refractory ascites, 23% for hyponatremia, 22% for hypoalbuminemia, 21% for edema, 9% for variceal bleeding, and 3% for hepatic encephalopathy. Preventive uses predominated: postparacentesis circulatory dysfunction (92%) and HRS (63%). For the three major indications (SBP, HRS, and paracentesis), patterns were relatively uniform (Fig. 1). However, one‐fifth of the respondents faced challenges in gaining access to IV albumin for their patients related to cost (75%), hospital guidelines (59%), and evidence (25%).Figure 1: This bar graph shows the percent of respondents who would use IV albumin or crystalloids for treatment of spontaneous bacterial peritonitis or hepatorenal syndrome and during large‐volume paracentesis in their patients. Abbreviations: HRS, hepatorenal syndrome; LVP, large‐volume paracentesis; SBP, spontaneous bacterial peritonitis.In this clinical US‐based AASLD member survey, there was considerable variation in IV albumin use, but most respondents administered albumin appropriately for SBP, HRS, and paracentesis. Most respondents also followed the AASLD guidelines not to administer fresh frozen plasma and platelets for large‐volume paracentesis2 and recognized a 0.3‐mg/dL increase in creatinine as a significant change requiring intervention.3