Human albumin helps perioperative management and prognosis improvement of liver transplantation patients

*Only for medical professionals to read and refer to Mr.
Albumin: "In the last issue, we have introduced that low albumin levels will not only affect the quality of life of patients waiting for liver transplantation, increase the risk of death during the transplant waiting period, and reduce their ability to accept liver transplantation.
The probability of transplantation is also related to acute kidney injury (AKI) after liver transplantation and large blood transfusion, which is a high-risk factor for patient death[1-6]
.
I
believe everyone is already unfavorable for the adverse effects of hypoalbuminemia on the prognosis of liver transplantation patients.
With a certain understanding of the impact, then in this issue we will share the positive effects of reasonable human albumin supplementation on the prognosis of such patients
.

"Because liver transplantation patients often have severe hypoalbuminemia, and many Studies have shown that low albumin levels are a high-risk factor for death in many patients.
Therefore, when the plasma albumin of patients with liver transplantation is low during the perioperative period, the necessary albumin should be supplemented in time [6]
.

Many experts and scholars at home and abroad have done a lot of in-depth research on the positive effects of rational use of human albumin during the perioperative period of liver transplantation patients
.

Of course, there is no shortage of guidelines and consensus authoritative suggestions on this topic
.

After sorting out, Mr.
Albumin summarized the following points for your reference: 1.
Human albumin treatment of decompensated liver cirrhosis ascites can significantly reduce the incidence of refractory ascites and improve the survival rate of patients.
Published in Liuye in 2018 A multi-center randomized, parallel, open-label trial on the knife [7] included patients with liver cirrhosis and simple ascites and divided them into a standard treatment control group and an observation group using albumin.
The observation group was given albumin ( Twice a week, 40 g each time for 2 weeks, then 40 g a week) treatment, the primary end point is 18-month mortality
.

The results showed that the incidence of refractory ascites in the observation group was significantly lower, and the overall survival rate was significantly higher [7]
.

2.
Human albumin combination therapy can improve the prognosis of patients with liver transplantation perioperative hepatorenal syndrome (HRS), and can be used as the first-line treatment of HRS.
In 2020, China's "Adult Chronic Acute Liver Failure Perioperative Management Experts in Liver Transplantation" Consensus [8] pointed out: patients with chronic acute liver failure (ACLF) often have HRS and non-HRS AKI
.

Visceral vasodilation is the most important factor that causes HRS.
Compared with albumin or placebo alone, vasopressin combined with albumin has a significant effect on reversing HRS
.

The consensus recommendation: ensure adequate renal perfusion and actively control infection
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Vasopressin combined with albumin therapy can help improve renal perfusion and can be used as a first-line treatment for HRS
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A foreign study [9] also confirmed that the transplant-free survival rate of patients receiving human albumin combination therapy was significantly higher than that of the control group
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The study included a total of 162 patients (including 102 cases of type 1 HRS and 60 cases of type 2 HRS), of which 75 patients received octreotide + midodrine + human albumin treatment (treatment group), 87 cases received no treatment (Control group), aiming to compare the curative effect of the treatment group and the control group
.

The average follow-up time of the two groups of patients was 115 days.
Finally, the transplant-free survival rate of the two groups was compared.
The results showed that the transplant-free survival rate of the patients receiving the combination therapy was significantly higher than that of the control group
.

The study concluded that the use of octreotide + midodrine + human albumin regimen as a transitional treatment for patients with type 1 hepatorenal syndrome to liver transplantation can bring significant benefits to patients and prevent the progression of type 2 hepatorenal syndrome It is type 1 hepatorenal syndrome
.

In addition, the "2015 British Blood Transfusion Board Albumin Guidelines" [10] also recommends that: human albumin is suitable for patients with hepatorenal syndrome eligible for liver transplantation, and 20% of human albumin should be combined with vasoactivity.
Drug combination
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The recommended dosage of human albumin is: 1 g of human albumin per kilogram of body weight is given to the patient on day 1, and 0.
5 g per kilogram of body weight on day 2-14 (stop when the patient's condition is relieved)
.

3.
The use of human albumin for restrictive fluid resuscitation during the perioperative period of liver transplantation can stabilize hemodynamics and reduce the risk of postoperative pulmonary insufficiency.
This item aims to explore early renal and respiratory insufficiency and intraoperative after liver transplantation.
A randomized controlled study on the relationship between fluid replacement [11], which included 67 patients with end-stage liver disease who received orthotopic deceased liver transplantation and randomly divided them into a restricted fluid resuscitation group (treated with albumin, frozen plasma and concentrated cells) And the non-restricted liquid group (10 mL/kg/hr normal saline)
.

The early postoperative respiratory function and renal insufficiency of the two groups of patients were evaluated
.

The results show that the use of albumin for restricted fluid resuscitation can maintain hemodynamic stability and significantly reduce the risk of postoperative pulmonary insufficiency
.

4.
Human albumin can be used to maintain the effective circulation volume of patients after liver transplantation "2013 Vanderbilt University Medical Center Multidisciplinary Surgical Intensive Care Albumin Management Guidelines" [12] Recommendation: liver resection (>40% ) After surgery, human albumin can be used to maintain the patient's effective circulation volume.
If liver transplantation patients have signs of hypovolemia after surgery and the lens treatment fails or there are contraindications to lens treatment, human albumin can be given for resuscitation
.

5.
Human albumin can be used to control ascites and peripheral edema in patients after liver transplantation.
"2017 Stanford Healthcare Guidelines for Intravenous Albumin Infusion" [13] Recommendation: If the serum albumin of patients after liver transplantation is less than 2.
5 g /dL, human albumin can be supplemented to control ascites and peripheral edema; the recommended method of using human albumin at this time is: use human albumin at a concentration of 25%, infusion at a dose of 25 g/d Note, until the patient's serum albumin is ≥2.
5 g/dL (if the patient's serum albumin is always less than 2.
5 g/dL, albumin treatment can be continued for up to 4 days; after that, if you consider continued use, you should consult a liver surgeon)
.

6.
Human albumin infusion after liver transplantation can protect organ function.
A foreign study [14] evaluated 15 cases of hypoalbuminemia after orthotopic liver transplantation and continuous infusion of human albumin (100 g/d).
) Data of 7-day patients (human albumin treatment group) were retrospectively analyzed, and these patients were compared with 15 patients (control group) who were paired with disease severity scores at admission
.

This study aims to explore the effects of human albumin supplementation on organ function after orthotopic liver transplantation
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The primary endpoint of the study was the difference in average sequential organ failure (SOFA) scores at 14 days after orthotopic liver transplantation
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The results showed that, compared with the control group, the average SOFA score of the patients in the human albumin treatment group was significantly lower 14 days after the operation
.

The results of this study suggest that continuous infusion of human albumin after orthotopic liver transplantation can protect organ function
.

Summary Albumin: "Many domestic and foreign studies and consensus guidelines have pointed out that the use of human albumin in the perioperative period of liver transplantation patients can help maintain effective circulation volume, control ascites and peripheral edema, and reduce the incidence of refractory ascites.
, Reduce the risk of postoperative pulmonary insufficiency, improve the prognosis of HRS patients, protect organ function, and improve the survival rate of patients
.

However, at this stage, there are still relatively few standards for the use of human albumin in the perioperative period of liver transplantation .
How patients should use human albumin is still controversial
.

More scholars are expected to do more in-depth research and discussion on this issue and standardize the clinical application of human albumin in liver transplantation patients
.

"Reference: [1] Ahn J,et al.
J Clin Gastroenterol.
2018 Jan 19.
[2] Chen J,et al.
Transplantation.
2011 Feb 15;91(3):348-53.
[3] McCluskey SA ,et al.
Liver Transpl.
2006 Nov;12(11):1584-93.
[4] Sang BH,et al.
Crit Care Med.
2015 Dec;43(12):2552-61.
[5] Jara M, et al.
Clin Transplant.
2014 Dec;28(12):1331-8.
[6] Cai Changjie.
Chinese Journal of Practical Surgery.
2007;27(8):610-13.
[7] Caraceni P, et al.
Lancet.
2018; 391:2417-29.
[8] Yi Huimin, Liu Jianrong, Lu Pinglan, Li Lijuan, Fan Mingming, Yi Xiaomeng, Lu Haijin, Wei Xuxia, Yang Yang, Chen Guihua.
Perioperative period of liver transplantation in adults with chronic onset acute liver failure Management Expert Consensus[J].
Organ Transplantation, 2020,11(05):533-542.
[9] Skagen C,et al.
J Clin Gastroenterol.
2009 Aug;43(7):680-5.
[10] Guys & St Thomas Hospital (2015) Guideline for the use of human albumin solution(HAS)Available: https:// demand20management20final.
pdf[11] Int J Organ Transplant Med.
2014;5(3):113-9.
[12] VUMC Multidisciplinary Surgical Critical Care Service Guidelines for Albumin Administration.
2013 Sep.
[13] Guidelines for Intravenous Albumin Administration at Stanford Health Care.
[14] Ertmer C,et al.
Clin Transplant.
2015 Jan;29(1): 67-75.
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