| Paracentesis |
Small volume (< 4 or 5 liters) - Use crystalloids as first choice (University Hospital Consortium, 2010). If management of condition is refractory to sodium restriction (90mmol/day), HA may be considered (Liumbruno et al., 2009). In patients with cirrhosis: HA may be indicated as option if there are concerns regarding use of synthetic colloids or crystalloids (volume overload, renal failure, coagulopathy) (Stanford Health Care, 2017; Guy’s and St. Thomas’ NHS Foundation Trust, 2015; Caraceni et al., 20166. Caraceni P, Angeli P, Prati D, Bernardi M, Alessandria C, Riggio O, et al. AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis. 2016 Jan;48(1):4-15.). Large volume (≥ 4 or 5 liters) - There is widespread consensus on the HA use (Vermeulen, Ratko, Erstad, 2010; Liumbruno et al., 2009). In patients with cirrhosis: Should be use HA and avoid combinations with other plasma expanders to reduce the dose of HA. Consider oral midodrine or terlipressin, mainly in critical care (Guy’s and St. Thomas’ NHS Foundation Trust, 2015; Caraceni et al., 2016; National Plasma Products Expert Advisory Group - Scotland NHS, 2016; Ontario Regional Blood Coordinating Network, 2012). |
20 g of albumin 20% per every 3L ascites drained or 20 g of albumin per every 2L if renal function impaired (Guy’s and St. Thomas’ NHS Foundation Trust, 2015; National Plasma Products Expert Advisory Group - Scotland NHS, 2016). 6 to 8 g of albumin 25% per every liter ascitic fluid removed (Vermeulen, Ratko, Erstad, 2010; Liumbruno et al., 2009; Stanford Health Care, 2017; Caraceni et al., 20166. Caraceni P, Angeli P, Prati D, Bernardi M, Alessandria C, Riggio O, et al. AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis. 2016 Jan;48(1):4-15.). |
| Hepatorenal Syndrome (HRS) |
For diagnosis of SuspectedA - HA may benefit. Diuretics use should be discontinued and considered volume expansion with HA for 2 consecutive days, then it should be evaluated if there was improvement of renal function (Vermeulen, Ratko, Erstad, 2010; Liumbruno et al., 2009; Stanford Health Care, 2017). In patients with cirrhosis: HA is used regularly (Caraceni et al., 20166. Caraceni P, Angeli P, Prati D, Bernardi M, Alessandria C, Riggio O, et al. AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis. 2016 Jan;48(1):4-15.). ConfirmedB - HA may be clinically indicated after 72 hours, nephrology and hepatology services should be consulted on the maintenance of the HA use. Should be used with vasoconstricting drugs (midodrine and octreotide) (Vermeulen, Ratko, Erstad, 2010; Liumbruno et al., 2009; Stanford Health Care, 2017; National Plasma Products Expert Advisory Group - Scotland NHS, 2016; Lyu et al.; 201611. Lyu PF, Hockenberry JM, Gaydos LM, Howard DH, Buchman TG, Murphy DJ. Impact of a Sequential Intervention on Albumin Utilization in Critical Care. Crit Care Med. 2016;44(7):1307-13.). Eligible for liver transplantation: HA should be used with vasoactive drugs, consider terlipressin (Guy’s and St. Thomas’ NHS Foundation Trust, 2015). In patients with cirrhosis: HA should be given with other vasoconstrictors (noradrenaline or midodrine plus octreotide) (Caraceni et al., 2016). |
Suspected - 1 g/kg of albumin 25% (up to 100 g) daily for 2 consecutive days (Vermeulen, Ratko, Erstad, 2010; Stanford Health Care, 2017; Guy’s and St. Thomas’ NHS Foundation Trust, 2015; Caraceni et al., 20166. Caraceni P, Angeli P, Prati D, Bernardi M, Alessandria C, Riggio O, et al. AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis. 2016 Jan;48(1):4-15.). Confirmed - Day 1: 1g/kg of albumin 5% or 20% Day 2 to 16: 20 to 40 g of albumin 5% or 20% daily (Vermeulen, Ratko, Erstad, 2010; National Plasma Products Expert Advisory Group - Scotland NHS, 2016) Day 1: 1 g/kg of albumin 20% or 25% Day 2 to14: 0.5 g/kg of albumin 20% or 25% daily (Guy’s and St. Thomas’ NHS Foundation Trust, 2015; Ontario Regional Blood Coordinating Network, 2012). Albumin should be given with vasoconstrictors (Caraceni et al., 2016; National Plasma Products Expert Advisory Group - Scotland NHS, 2016). |
| Spontaneous Bacterial Peritonitis (SBP) |
HA may be used. Some authors recommend use of HA according clinical conditions (including patients with cirrhosis) (Vermeulen, Ratko, Erstad, 2010; Stanford Health Care, 2017; Guy’s and St. Thomas’ NHS Foundation Trust, 2015; National Plasma Products Expert Advisory Group - Scotland NHS, 2016; Ontario Regional Blood Coordinating Network, 2012). Low-risk patients
C - decision on use of HA should be individualised; HA use could be restricted to “high” risk patients. High-risk patients - HA administration is mandatory for patients with cirrhosis and is not recommended the use of crystalloids and synthetic colloids or association these with HA (Caraceni et al., 20166. Caraceni P, Angeli P, Prati D, Bernardi M, Alessandria C, Riggio O, et al. AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis. 2016 Jan;48(1):4-15.; National Plasma Products Expert Advisory Group - Scotland NHS, 2016). |
Day 1: 1.5 g/kg of albumin 5%, 20% or 25%. Day 3: 1 g/kg of albumin 5%, 20% or 25%. (Caraceni et al., 20166. Caraceni P, Angeli P, Prati D, Bernardi M, Alessandria C, Riggio O, et al. AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis. 2016 Jan;48(1):4-15.; National Plasma Products Expert Advisory Group - Scotland NHS, 2016). Albumin should be given in association with antibiotics (Guy’s and St. Thomas’ NHS Foundation Trust, 2015). |
| Severe Nephrotic Syndrome |
HA may be considered in cases with severe refractory edema or symptoms and signs of sub-acute intravascular volume depletion, including oliguria, poor peripheral perfusion, abdominal pain, raised creatinine and haematocrit; always under supervision of consultant paediatric nephrologist (Guy’s and St. Thomas’ NHS Foundation Trust, 2015). |
1g/kg of albumin 20% over 6 hours, with or without loop diuretic (Guy’s and St. Thomas’ NHS Foundation Trust, 2015). |
| Maldistributive shock |
Crystalloids should be considered first-line therapy (Vermeulen, Ratko, Erstad, 2010; National Plasma Products Expert Advisory Group - Scotland NHS, 2016). Inappropriate use of HA (Stanford Health Care, 2017). Maybe used in patients with refractory septic shock who have received resuscitation with crystalloid and require >0.2mcg/kg/min of norepinephrine (Guy’s and St. Thomas’ NHS Foundation Trust, 2015). Consider use of HA in critical care (Lyu et al., 201611. Lyu PF, Hockenberry JM, Gaydos LM, Howard DH, Buchman TG, Murphy DJ. Impact of a Sequential Intervention on Albumin Utilization in Critical Care. Crit Care Med. 2016;44(7):1307-13.). |
Adults: 20 to 40 g of albumin over 30 to 60 minutes (Guy’s and St. Thomas’ NHS Foundation Trust, 2015). Children: Without evidence. |
