The use of human albumin for the management of cirrhosis has increased. Recommendations have been published for therapeutic paracentesis (TP), spontaneous bacterial peritonitis (SBP), and type 1 hepatorenal syndrome (HRS). The goal of this survey was to assess the prescription practices of French hepatogastroenterologists.All hepatogastroenterologists were contacted. The questionnaire evaluated (1) the use of albumin in validated indications and (2) the prescription of albumin for nonvalidated clinical situations.Responses were analyzed from 451 (50.1%) practitioners. The mean age was 40 years (range, 24 to 67 y). Physicians practiced in a university hospital (47.7%) or a general hospital (45.8%). There were 56.7% senior practitioners. Overall 99.6% of the practitioners compensated for TP. Albumin was used by 87.8% of the physicians, with a fixed dose being used by 84.6%. For SBP, 94% of the physicians used albumin concomitantly with antibiotics. The recommended protocol was followed by 56.2% of the practitioners: more often by senior university hospital practitioners than by senior general hospital practitioners (P=0.015). About 66.5% used albumin infusion for the diagnosis of HRS: used more often by senior university hospital practitioners (P=0.0006). Albumin was used concomitantly with vasopressor treatment by 84%; the dose and the duration varied considerably. About 23.5% used albumin for severe bacterial infection, 47.9% for severe hyponatremia, 43.9% for severe hypoalbuminemia, and 65.9% for hydrothorax.In this large French survey, albumin is only prescribed in accordance with recommendations for TP. The schedule for SBP is followed by only 56% of the practitioners. The use of albumin for HRS is not adapted to recommendations, which are not well known, suggesting that they should be more diffused.
Les perfusions d’albumine ont pris une place importante dans le traitement des complications de la cirrhose. Trois indications sont validees et font l’objet de recommandations : la prevention de la dysfonction circulatoire post-paracentese, l’infection spontanee du liquide d’ascite (ISLA) et le syndrome hepatorenal de type 1. D’autres indications potentielles sont en cours d’evaluation. Pour autant, les mecanismes d’action de l’albumine sont encore tres incompletement elucides. Pendant longtemps, son utilisation s’est fondee sur ses proprietes oncotiques et sa capacite de remplissage vasculaire. Ce n’est que recemment que d’autres effets hemodynamiques de l’albumine ont ete mis en evidence. Chez le patient cirrhotique, d’une part, elle ameliore la dysfonction endotheliale, reduit la vasodilatation peripherique et augmente la reactivite aux vasoconstricteurs, et d’autre part, elle augmente la contractilite cardiaque. Ces « nouveaux » effets sont medies par differentes proprietes anti-oxydantes, anti-inflammatoires, immunomodulatrices, de transport, et de detoxification. En particulier, l’albumine semble jouer un role important dans la regulation des effets du monoxyde d’azote sur l’endothelium vasculaire. Chez le patient cirrhotique, a la reduction de la quantite d’albumine (hypoalbuminemie) s’associent des alterations qualitatives de la molecule. Alors que 70 % de l’albumine circule sous forme non oxydee chez le sujet sain, au cours de la cirrhose les formes oxydees deviennent predominantes. Ces donnees recentes ont conduit a proposer un nouveau concept de « concentration d’albumine efficace ». Dans ce cadre, il est interessant de noter que la qualite des preparations commerciales d’albumine, appreciee sur le pourcentage de formes oxydees, est tres variable, sans que l’on sache encore dans quelle mesure cela affecte leurs effets therapeutiques.
Background. Chronic viral hepatitis averages 15% to 20% in heart transplant patients. Several studies have shown that ursodiol may improve liver biochemistry in patients with chronic hepatitis. We used a double-blind randomized controlled trial to evaluate the effect of ursodiol in heart transplant patients with chronic viral hepatitis. Methods. Thirty heart patients with chronic viral hepatitis B, C, or non-A-G received ursodiol, 800 mg per day (group 1), and 30 received placebo (group 2) for 12 months. Endpoints were improvement in liver biochemical tests and in total Knodell score. Intent-to-treat and per-protocol analyses were performed. Results. At entry, both groups were comparable for all of the studied parameters. During the study period, serum alanine aminotransferase, aspartate aminotransferase, and γ-glutamyl transpeptidase variations were not different between group 1 and group 2 patients. Knodell score improved in 20% of group 1 patients and in 43% of group 2 patients (NS). Adverse events or mortality were not different in the two groups during the study period. Similar results were observed by intent-to-treat and per-protocol analyses. Conclusions. A 12-month course of ursodiol therapy had no effect on liver enzymes or liver histology in heart transplant patients with chronic hepatitis.
Tenofovir disoproxil fumarate (TDF) demonstrated potent and sustainable antiviral efficacy and a good safety profile in patients with chronic hepatitis B (CHB) in controlled clinical trials. Real-world data are important to confirm effectiveness and safety data in patient populations encountered in routine clinical practice. This non-interventional, prospective, 36-month study included treatment-naïve and treatment-experienced patients with CHB initiating their first TDF regimen (monotherapy or combination therapy) in routine clinical practice in France. Clinical, virologic, biochemical, compliance, and safety data were collected. Data from 440 consecutive patients from 58 centers were analyzed. The majority of the cohort was male (71 %), hepatitis B "e" antigen-negative (HBeAg–) (74 %), and treatment-experienced (56 %); 11 % were aged ≥65 years; and comorbidities were reported in 39 %. After 12 months, 92 % of the overall cohort achieved virologic response (HBV DNA <69 IU/mL) which was maintained to 36 months (96 %); virologic response was achieved by >90 % of patients irrespective of HBeAg status, age, or prior treatment history. At 36 months, 77 % of patients had normal alanine aminotransferase levels. Fourteen patients lost hepatis B surface (HBs) antigen, and seven seroconverted to anti-HBs. TDF was well tolerated over the 36-month study, including in 14 women who became pregnant during the study. Median estimated glomerular filtration rate did not change markedly from baseline irrespective of prior treatment history. TDF demonstrated potent virologic and biochemical responses across a broad range of patients reflective of routine clinical practice. The safety profile was consistent with results from pivotal trials.
Albumin constitutes an essential treatment in clinical hepatology. After large volume paracentesis, there is a high risk of circulatory disturbance which is associated with a shorter time to readmission for ascites and shorter survival. Albumin infusion (7 g/l of ascitic fluid removed) reduces the incidence of this circulatory dysfunction from more than 75 % when the procedure is performed without albumin to approximately 15 % when it is used. In patients with spontaneous bacterial peritonitis, albumin infusion in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. This beneficial effect is mainly observed in high risk patients HEPATOnGASTRO et Oncologie digestive
