SFGH pearls: Cirrhosis, albumin and HRS!

  • Current indications for albumin use include treatment of SBP, treatment of Type I HRS, and fluid replacement after large volume para (>5L)
    • There is no strong evidence to date that albumin replacement for patients with ascites due to cirrhosis improves survival, though one study suggested it may prevent ascites reaccumulation, reduce length of hospital and reduce readmissions.
    • A recent article investigating the role of albumin presents evidence that it not only increases oncotic pressure (the traditionally accepted benefit), but also may result in immune modulation, anti-thrombotic function, anti-oxidant function and endothelial stabilization. Many potential applications are being studied, so stay tuned!
  • In paracentesis with high RBC counts, there is a correction for the white count:
    • Subtract one WBC from the total count for every 750 RBCs
    • Subtract one neutrophil from the neutrophil count for every 250 RBCs
      • This correction may give a WBC or PMN count of <0, which is theorized to be due to lysis of PMNs in the setting of hemorrhage
    • Patients with HRS who respond to medical therapy with octreotide, midodrine and albumin usually continue treatment for 2 weeks, with the course extended as needed if renal failure is still resolving at that point.
    • In patients with HRS who do not respond to medical therapy, HD is usually only offered to those awaiting transplant or if improved liver function is possible/expected in the near future, as survival in these patients is usually limited by hepatic failure.

Evernote link: https://www.evernote.com/shard/s300/sh/f7bb3a97-bdcf-4d42-bdbc-8c607e480622/b5f7ad7a278750b3c5a050f3b8d1a586

Gentilini P, Casini-Raggi V, Di Fiore G, Romanelli RG, Buzzelli G, Pinzani M, La Villa G, et al. Albumin improves the response to diuretics in patients with cirrhosis and ascites: results

Spinella R1, Sawhney R2, Jalan R3. Albumin in chronic liver disease: structure, functions and therapeutic implications. Hepatol Int. 2015 Sep 29. [Epub ahead of print]

Hoefs JC. Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease. Hepatology 1981; 1:249.

Wilkinson SP, Weston MJ, Parsons V, Williams R. Dialysis in the treatment of renal failure in patients with liver disease. Clin Nephrol 1977; 8:287.

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