Information sourced from NEJM Journal Watch:
Adding IV Albumin to Lactulose Improves Outcomes in Severe Hepatic Encephalopathy
This combination sped encephalopathy reversal and lowered inpatient mortality.
Intravenous (IV) albumin might reduce oxidative stress by decreasing levels of circulating cytokines and endotoxins (NEJM JW Hosp Med Jan 2014 and Hepatology 2013; 58:1836). A 2013 study showed that IV albumin lowered risk for 90-day mortality in patients with hepatic encephalopathy (HE; J Hepatol 2013; 59:1184). In a new trial, researchers in India randomized 120 cirrhotic patients with severe HE (mean baseline serum albumin level, 2.3 g/dL; 78% with West-Haven Grade 3 or 4 encephalopathy) to IV albumin (1.5 g/kg/day) plus lactulose or to lactulose therapy alone.
Patients who received albumin were significantly more likely than lactulose-only patients to experience complete reversal of HE within 10 days (75% vs. 53%; number needed to treat [NNT], 5), shorter mean hospital length of stay (LOS; 6.4 vs. 8.6 days), and lower inpatient mortality (18% vs. 32%; NNT, 8). Mean serum inflammatory cytokine and endotoxin levels were lowered significantly more in the albumin group than in the lactulose-only group.
Limitations of this study include its open-label design and small sample size; also, these patients did not receive rifaximin (Xifaxan), which prevents short-term mortality in severely encephalopathic patients, as part of their therapeutic regimen (NEJM JW Hosp Med Nov 2013 and Am J Gastroenterol 2013; 108:1458). In addition, the high cost of IV albumin could limit early adoption of this intervention. Nevertheless, the impressive mortality benefit and LOS reduction make IV albumin a worthwhile consideration in hospitalized patients with severe hepatic encephalopathy, especially in those who need intravascular volume expansion.
Kara Raphael, MD, Sheri-Ann Peckham, BS, Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Sharma BC et al. J Gastroenterol Hepatol 2016 Nov 25.
Dr. Raphael is a senior Internal Medicine resident at Emory University in Atlanta, Georgia.
Ms. Peckham is a third-year medical student at Emory University School of Medicine in Atlanta, Georgia.
At the time NEJM Journal Watch reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Sharma BC et al. A randomized controlled trial comparing lactulose plus albumin versus lactulose alone for treatment of hepatic encephalopathy. J Gastroenterol Hepatol 2016 Nov 25; [e-pub].
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