Long-Term Albumin administration: a survival benefit in cirrhotic refractory ascites beyond TIPS eligibility

Background and Aims

Evidence suggests that long-term albumin administration (LTA) prolongs overall survival in patients with cirrhosis and refractory ascites. However, LTA is not yet standard care, and the effects of its combination with TIPS (Transjugular Intrahepatic Portosystemic Shunt) placement remains unclear.

Methods

This observational study compared two groups of patients with cirrhosis and ascites who required at least one large volume paracentesis (LVP). The first group, observed from January 2019 to December 2021, received standard medical treatment (SMT: diuretics and albumin administration after LVP). The second group, observed from January 2022 to February 2024, received SMT plus LTA at a dosage of 40 mg/week. The primary endpoint was mortality and the cause-specific Cox model was used to estimate covariate effects. The Fine and Gray competing risks regression model was used account for death, and LT as competing risk.

Results

A total of 153 patients were analyzed: 63 in the SMT+LTA group and 90 in the SMT group. No differences in liver disease etiology, age, gender, Child-Pugh score, presence of Hepatocellular Carcinoma(HCC), Hepatic Encephalopathy(HE), and eligibility for TIPS and OLT are observed between the two groups.

During the follow-up(median 9 months; range 2-67), 11 patients in the LTA group(17.4%) and 9 in the SMT group(10%) underwent TIPS(p=ns), 7(11.1%) and 8(9%) patients were transplanted in LTA and SMT group respectively(p=ns), and 16 patients in the LTA group(25.4%) versus 71 in the SMT group(79%) died(p<0.001).

Multivariate analysis showed that LTA(HR:0.16; p<0.001), creatinine(HR:1.40; p=0.025), bilirubin (HR:1.16; p=0.014), viral etiology (HR:0.24; p=0.013), and TIPS placement (HR:0.10; p<0.001) were independently associated with mortality. The same results were observed when substituting TIPS placement with TIPS eligibility (Figure 1).

Conclusions

For patients with refractory ascites, LTA in addition to SMT significantly prolongs overall survival and may serve as a disease-modifying treatment, particularly for those contraindicated for TIPS.