Practice patterns and outcomes associated with intravenous albumin in patients with cirrhosis and acute kidney injury

Abstract

Background & Aims: Guidelines recommend albumin as the plasma-expander of choice for acute kidney injury (AKI) in cirrhosis. However, the impact of these recommendations on patient outcomes remains unclear. We aimed to determine the practice-patterns and outcomes associated with albumin use in a large, nationwide-US cohort of hospitalized cirrhotics with AKI.Methods: A retrospective cohort study was performed in hospitalized cirrhotics with AKI using Cerner-Health-Facts database from January 2009 to March 2018. 6786 were included for analysis on albumin-practice-patterns, and 4126 had available outcomes data. Propensity-score-adjusted model was used to determine the association between albumin use, AKI-recovery and in-hospital survival.Results: Median age was 61-years (60% male, 70% white), median serum-creatinine was 1.8 mg/dL and median Model for End-stage Liver Disease Sodium (MELD-Na) score was 24. Albumin was given to 35% of patients, of which 50% received albumin within 48-hours of AKI-onset, and 17% received appropriate weight-based dosing.Albumin was used more frequently in patients with advanced complications of cirrhosis, higher MELD-Na scores and patients admitted to urban-teaching hospitals. After propensity-matching and multivariable adjustment, albumin use was not associated with AKI-recovery (odds ratio [OR] 0.70, 95% confidence-interval [CI]: 0.59-1.07, P = .130) or in-hospital survival (OR 0.76 [95% CI: 0.46-1.25], P = .280), compared with crystalloids. Findings were unchanged in subgroup analyses of patients with varying cirrhosis complications and disease severity. Conclusions: USA hospitalized patients with cirrhosis and AKI frequently do not receive intravenous albumin, and albumin use was not associated with improved clinical outcomes. Prospective randomised trials are direly needed to evaluate the impact of albumin in cirrhotics with AKI.

Prognostic significance of acute kidney injury stage 1B in hospitalized patients with cirrhosis: A US nationwide study

“…Nevertheless, the underutilization of albumin use provides a key area for quality improvement in the management of AKI in patients with cirrhosis. [20] Lastly, despite using validated ICD-9/10 codes that carry high sensitivity for the diagnosis of cirrhosis, the possibility for cirrhosis misclassification may exist. Despite the limitations of our study, there are also several strengths.…”

“…However, compared with Huelin et al, 1 the AKI recovery rates for stage 1A in our study were similar (90% vs. 86.9%) and higher in stage 1B, 50% versus 68.9%. Nevertheless, the underutilization of albumin use provides a key area for quality improvement in the management of AKI in patients with cirrhosis 20 . Lastly, despite using validated ICD-9/10 codes that carry high sensitivity for the diagnosis of cirrhosis, the possibility for cirrhosis misclassification may exist.…”

“…Patients with stage 1B had a higher prevalence of preexisting CKD compared with stage 1A patients, 59.9% vs. 8.7% (p < 0.001), and had significantly higher median baseline sCr, 1.66 (1.20, 1.97) vs. 0.74 (0.60, 0.90) mg/dL (p < 0.001), respectively. Moreover, patients with stage 1B had significantly higher median sCr at time of AKI diagnosis compared with stage 1A patients, 2.20 (1.72, 3.34) vs. 1.10 (0.94, 1.30) mg/dL (p < 0.001), respectively, and accordingly had significantly higher MELD-Na scores [25 (20,29) vs. 18 (11,24) in 1A, p < 0.001] at the time of AKI diagnosis. Furthermore, patients with stage 1B had higher rates of nonspontaneous bacterial peritonitis infections compared with stage 1A patients, 30.8% vs. 26.6% (p < 0.001), respectively.…”

Management of patients with cirrhosis in the emergency department: Implications for hospitalization outcomes

“…Fluids should be administered to all patients with cirrhosis and AKI when hypovolemia is suspected, in accordance with the cause and severity of fluid loss 5,6 . A large recent retrospective analysis found that albumin infusion was not associated with superior outcomes in comparison with crystalloids for AKI in patients with cirrhosis 41 . However, in cases of stage 2 or greater AKI (increase in serum creatinine > 2-fold from baseline) of unclear etiology, consensus guidelines recommend administering albumin at a dose of 1 g/kg for 2 days to distinguish HRS-AKI from other prerenal causes 5,6 …”

“…[5,6] A large recent retrospective analysis found that albumin infusion was not associated with superior outcomes in comparison with crystalloids for AKI in patients with cirrhosis. [41] However, in cases of stage 2 or greater AKI (increase in serum creatinine > 2-fold from baseline) of unclear etiology, consensus guidelines recommend administering albumin at a dose of 1 g/kg for 2 days to distinguish HRS-AKI from other prerenal causes. [5,6] HYPONATREMIA Hyponatremia is very common among patients with cirrhosis and is associated with increased mortality.…”