Outpatient Intravenous Albumin Decreases Hospitalization and Mortality in Patients with Cirrhosis

Abstract

Main Research Question: What is the effect of routine outpatient albumin infusion on the incidence of hospitalization and mortality in patients with end stage liver disease within a one year time period?

Background, Significance and Rationale: Administration of intravenous human albumin therapy has an important role in the management of spontaneous bacterial peritonitis, acute kidney injury, and reduction in risk of circulatory dysfunction following paracentesis. We hypothesized that albumin infusions given on an outpatient basis with increasing frequency will improve volume management and outcomes in patients with cirrhosis and refractory ascites or anasarca. Methods: We examined consecutive patients with cirrhosis and refractory ascites who initiated an outpatient intravenous human albumin treatment protocol. All patients received at least one albumin infusion of 25% human albumin 50g which was given independently from albumin received during paracenteses between the years of 2011 and 2015. Patients with transjugular intrahepatic portosystemic shunts (TIPS) were excluded. Laboratory and clinical data during the three months before and longitudinal follow up over 12 months was assessed, including hospitalizations, transplantation and overall survival.

Results: 97 patients received at least one outpatient infusion of albumin. Patient demographics included median age 62 (range 38-86), 64% male, 86% Caucasian, 43% cryptogenic/nonalcoholic fatty liver disease and 34% chronic hepatitis C. Primary presentation included ascites 74%, hepatic hydrothorax 13%, and anasarca 12%. Median Model for End-Stage Liver Disease (MELD) score was 15 (6-29) with 24% MELD >20 and 51% of patients required hospitalizations within three months prior to initiation of outpatient albumin protocol. 18% of patients received a transplant by 12 months and 69% died during follow up. The median frequency of albumin infusions among patients was one infusion every 3 weeks and 40% received albumin infusions at least once every 2 weeks. Frequency of hospitalizations was decreased at 3 months (p=0.04), 6 months (p=0.04), and 12 months (p=0.08) among patients who had infusions at least every 2 weeks. Competing-risks regression was performed, demonstrating patients who received albumin infusions at least once every 2 weeks during the first 12 months had a lower cumulative incidence of death accounting for liver transplantation as a competing event (p=0.05), independent of sustained virologic response with chronic hepatitis C treatment and MELD score (p = 0.04).

Conclusions: Outpatient intravenous human albumin infusions every 2 weeks or more is associated with decreased risk of hospitalization and mortality in patients with cirrhosis who were not candidates for TIPS procedure. Albumin therapy may improve outcomes through enhanced volume management and reduced incidence of complications.