How albumin administration for cirrhosis impacts on hospital albumin consumption and expenditure

Table 1 Levels of evidence and strength of recommendation

Levels of evidence
1	Randomized clinical trials and/or meta-analyses
2	Single randomized clinical trail
3	Prospective observational studies
4	Retrospective studies
5	Cross-sectional surveys and descriptive studies
6	Opinion of experts in guidelines or consensus
Strength of recommendations
A	Strong (levels of evidence 1 and 2)
B	Relatively strong (levels of evidence 3, 4 and 5)
C	Weak (level of evidence 6)

Table 2 Practical recommendations for the prescription of albumin at the S Orsola-Malpighi University Hospital, Bologna, Italy

Acute diseases	First-line treatment	Second-line treatment
Hypovolemic shock [1, A]	Colloid/crystalloid solutions	Human albumin if:
		Sodium intake restriction
		Hypersensitivity to colloids or crystalloids
		Lack of response to combined use of colloids and crystalloids
Major surgery [6, C]
(1) Cardiovascular surgery	Colloid/crystalloid solutions	Human albumin if:
		Lack of response to combined use of colloids and crystalloids
		As for hypovolemic shock
(2) Other surgery	As for hypovolemic shock
Burns [6, C]	Colloid/crystalloid solutions	Human albumin plus crystalloid solutions if:
		Lack of response to colloid or crystalloid solutions alone
		Severe burns (> 50% body surface)
Chronic diseases	First-line treatment	Second-line treatment
Cirrhosis	Human albumin
(1) Paracentesis [1, A]	8 g/L of removed ascites if paracentesis > 4 L
(2) Spontaneous bacterial peritonitis [1, A]	1.5 g/kg at diagnosis and 1 g/kg on third day + antibiotic therapy
(3) Hepatorenal syndrome [1, A]	1 g/kg at diagnosis followed by 20-40 g/d + vasoconstrictors
(4) Ascites [1, A]	Diuretic treatment	Human albumin if: Ascites resistant to diuretics
Plasmapheresis [6, C]	Human albumin if plasma changes > 20 mL/kg per week
Protein wasting enteropathy/malnutrition	Enteral or parenteral nutrition	Human albumin only if:
		severe diarrhea (> 2 L/d)
		albuminemia < 2 g/dL
		clinical hypovolemia

Albumin is not recommended for cerebral ischemia (3, B), wound-healing (6, C), chronic pancreatitis (6, C), nephritic syndrome (6, C). Albumin is also provided for the following specific procedures: pulmonary endarterectomy, molecular adsorbent recirculating system (MARS), immunomagnetic selection system (CLINIMACS).

Table 3 Distribution of albumin consumption and cost among clinical indications in 2008

	Vials (number)(%)	Cost (euros)	Patients (number)(%)	Vials/patients (number)	Cost/patient (euros)
Cirrhosis	19 871 (52)	534.532	807 (36.3)	24.6	662
Major surgery	6196 (16.2)	166.982	495 (22.2)	12.5	337
Shock	5069 (13.3)	136.558	447 (20)	11.3	305
Enteric disease	2982 (7.8)	80.215	146 (6.5)	20.4	549
Plasmapheresis	2333 (6.1)	62.757	54 (2.4)	43.2	1162
Mars	196 (0.5)	5.272	6 (0.2)	32.6	878
Others1	201 (0.5)	5353.000	149 (6.7)	7.1	260
Extra-protocol	1240 (3.7)	33.418	119 (5.3)	10.5	281

¹Others: Clinimacs system, neonatal jaundice, pediatric cardio-pulmonary bypass.

Table 4 Distribution of albumin consumption and cost among the clinical indications for cirrhosis in 2008

	Vials (number)(%)	Cost (euros)	Patients (number)(%)	Vials/patients (number)	Cost/patient (euros)
Ascites	12.540 (63.3)	337.976	453 (56.4)	27.7	746
Paracentesis	4.564 (23.1)	122.988	222 (27.6)	20.6	554
Hepatorenal syndrome	2.340 (11.8)	63.070	106 (13.2)	22.0	595
Spontaneous bacterial peritonitis	367.000 (1.8)	9.880	22 (2.7)	14.0	380