Outpatient Intravenous Albumin Decreases Hospitalization and Mortality in Patients with Cirrhosis and Refractory Ascites or Anasarca

Purpose: Albumin improves survival and outcomes associated with complications of cirrhosis including spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, and volume overload. The role of outpatient intravenous albumin infusions in decreasing hospitalizations and mortality in this population has not been well established. Methods: A retrospective electronic medical record review of cirrhotic patients with refractory ascites or anasarca who underwent outpatient intravenous albumin therapy between the years of 2011 and 2015 was performed. All patients received at least one albumin infusion of 25% albumin 50 g which was given independently from albumin received during paracenteses. Patients with transjugular intrahepatic portosystemic shunts (TIPS) were excluded. Laboratory, clinical data, and hospitalizations 3 months before initiation of albumin therapy and longitudinal follow up over 12 months were assessed, including hospitalizations, transplantation and overall survival. Results: 97 patients received at least one outpatient albumin infusion. Patient demographics included median age 62 (range 38-86), 64% male, 86% Caucasian, 36% cryptogenic/nonalcoholic fatty liver disease and 34% chronic hepatitis C. Median Model for End-Stage Liver Disease (MELD) score was 15 (6-29) with 24% MELD >20 and 51% of patients required hospitalizations within 3 months prior to initiation of albumin infusions. 18% of patients received a transplant by 12 months and 69% died during follow up. The median frequency of albumin infusions among patients was one infusion every 3 weeks and 40% received albumin infusions at least once every 2 weeks. Frequency of hospitalizations was decreased at 3 months (p=0.04), 6 months (p=0.04), and 12 months (p=0.08) among patients who had infusions at least every 2 weeks. Competing-risks regression was performed, demonstrating patients who received albumin infusions at least once every 2 weeks during the first 3 months had a lower cumulative incidence of death accounting for liver transplantation as a competing event (p=0.05), independent of sustained virologic response with chronic hepatitis C treatment and MELD score (p = 0.04). Conclusions: Outpatient intravenous albumin infusions decrease incidence of hospitalization and mortality in cirrhotic patients with refractory ascites or anasarca who are not candidates for TIPS placement.