Albumin infusion in cirrhotic patients with infections other than spontaneous bacterial peritonitis: End of the story?
Authors: Manuela Merli, Cristina Lucidi, Barbara Lattanzi, Oliviero Riggio
Journal: Journal of Hepatology (2015)

Effect of albumin in cirrhotic patients with infection other than spontaneous bacterial peritonitis. A randomized trialJournal of HepatologyVol. 62Issue 4PreviewAlbumin infusion improves renal function and survival in cirrhotic patients with spontaneous bacterial peritonitis (SBP) but its efficacy in other types of infections remains unknown. We investigated this issue through a multicenter randomized controlled trial. Full-Text PDF Reply to "Albumin infusion in cirrhotic patients with non-SBP infections: End of the story?"Journal of HepatologyVol. 63Issue 3PreviewWe greatly appreciate the comments by Lucidi et al. [1]. Firstly, we acknowledge that, despite well-conducted randomization to reduce the risk of selection bias at trial entry [2], the presence of ascites was more frequently reported in the albumin (ALB) group as compared with the control group (75.8 vs. 59.6; p = 0.017). We have to remember that using an alpha risk of 5%, the probability of there being no imbalance between groups for any one baseline characteristic is 0.95. Assuming the characteristics are independent, there is a non-negligible 1 − (0.95)n probability of observing a significant imbalance between groups when comparing n baseline characteristics. Full-Text PDF Open Access We read with interest the recent manuscript by Thevenot et al. [[1]Thévenot T. Bureau C. Oberti F. Anty R. Louvet A. Plessier A. et al.Effect of albumin in cirrhotic patients with infections other than spontaneous bacterial peritonitis: a randomized trial.J Hepatol. 2015; 62: 822-830Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar] which adds data to the debate on the potential beneficial effect of albumin administration during episodes of infections other than spontaneous bacterial peritonitis (SBP) in cirrhotic patients [2Guevara M. Terra C. Nazar A. Solà E. Fernández J. Pavesi M. et al.Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study.J Hepatol. 2012; 57: 759-765Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar, 3Thevenot T. Monnet E. Di Martino V. Effect of albumin on survival in septic cirrhotic patients other than spontaneous bacterial peritonitis. The question remains open.J Hepatol. 2013; 58: 638-639Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 4Guevara M. Arroyo V. Ginès P. Reply to: "Effect of albumin on survival in septic cirrhotic patients other than spontaneous bacterial peritonitis. The question remains open".J Hepatol. 2013; 58: 640Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. In this multicentre study, 193 cirrhotic patients with infections other than SBP, were randomly assigned to receive albumin infusion or no treatment in addition to antibiotics. The primary outcomes were renal failure and mortality rates. The study failed to show any beneficial effect on these outcomes, although albumin infusion delayed the onset of renal failure. However, in our opinion, some bias could have influenced the results. First, the prevalence of ascites was significantly higher in the patients randomized to albumin and antibiotics than in the patients assuming antibiotics alone (75.8 vs. 59.6%; p = 0.017). The development of infection and the consequent increase in vasodilatation may have influenced the rate of renal failure and prognosis of the former group differently from the control group in which the number of patients with ascites was lower. Second, the success or failure of antibiotic therapies were not analyzed and, as we know, the course of infections is a further important parameter for the prognosis of cirrhotic patients [5Arvaniti V. D'Amico G. Fede G. Manousou P. Tsochatzis E. Pleguezuelo M. et al.Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis.Gastroenterology. 2010; 139: 1246-1256Abstract Full Text Full Text PDF PubMed Scopus (768) Google Scholar, 6Merli M. Lucidi C. Giannelli V. Giusto M. Riggio O. Falcone M. et al.Cirrhotic patients are at risk for health care-associated bacterial infections.Clin Gastroenterol Hepatol. 2010; 8: 979-985Abstract Full Text Full Text PDF PubMed Scopus (222) Google Scholar]. Third, as also discussed by the authors, many violations occurred in the protocol and 17 patients in the control group also received albumin for large volume paracentesis during the first week. Thus, in our opinion, the results of the present study should not discourage further investigations in cirrhotic patients with infections also considering the wide range of potential benefits of albumin administration in this setting (antioxidant function, immunomodulation, anti-inflammatory activity and transport of many endogenous and exogenous substances), in addition to its well-known effect as plasma expander [[7]Caraceni P. Domenicali M. Tovoli A. Napoli L. Ricci C.S. Tufoni M. et al.Clinical indications for the albumin use: still a controversial issue.Eur J Intern Med. 2013; 24: 721-728Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar]. Among these additional properties, in particular, the effect of the albumin infusion during the therapy with moderately/highly protein-bound antibiotics should also be evaluated, considering the relevant role of hypoalbuminemia on the pharmacokinetics of these antibiotics [[8]Roberts J.A. Abdul-Aziz M.H. Lipman J. Mouton J.W. Vinks A.A. Felton T.W. et al.Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions.Lancet Infect Dis. 2014; 14: 498-509Abstract Full Text Full Text PDF PubMed Scopus (622) Google Scholar]. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.