Background & Aims
The choice of resuscitation fluid in patients with cirrhosis and sepsis-induced hypotension
is unclear. 5% albumin was superior to normal saline in the FRISC study. We compared
the efficacy and safety of 20% albumin, which has greater oncotic properties, to plasmalyte
in reversing sepsis-induced hypotension.
Critically ill patients with cirrhosis underwent open-label randomization to receive
either 20% albumin (0.5-1.0 g/kg over 3 hours; n = 50) or plasmalyte (30 ml/kg over
3 hours, n = 50). The primary endpoint of the study was the attainment of mean arterial
pressure (MAP) above 65 mmHg at 3 hours.
Baseline characteristics were comparable in albumin and plasmalyte groups; arterial
lactate (6.16±3.18 mmol/L vs. 6.38±4.77 mmol/L; p = 0.78), MAP (51.4±6.52 mmHg vs. 49.9±4.45 mmHg; p = 0.17) and SOFA score (10.8±2.96 vs. 11.1±4.2; p = 0.68), respectively. Most patients were alcoholics (39%) and had pneumonia (40%).
In the intention-to-treat analysis, albumin was superior to plasmalyte in achieving
the primary endpoint (62% vs. 22%; p <0.001). A faster decline in arterial lactate (p = 0.03), a reduced need for dialysis (48% vs. 62%; p = 0.16), and a longer time to initiation of dialysis (in hours) (68.13±47.79 vs. 99.7± 63.4; p = 0.06) were seen with albumin. However, the 28-day mortality rate was not different
(58% vs. 62%, p = 0.57) and treatment had to be discontinued in 11 (22%) patients in the albumin group
due to adverse effects compared to no discontinuations in the plasmalyte group.
In patients with cirrhosis and sepsis-induced hypotension, 20% albumin leads to a
faster improvement in hemodynamics and lactate clearance than plasmalyte, while 28-day
survival was similar. However, patients on 20% albumin need to be closely monitored
as it was more often associated with pulmonary complications.
Clinical trial registration
The current randomized-controlled trial performed in critically ill patients with
cirrhosis and sepsis-induced hypotension highlights that 20% albumin restores arterial
pressure more quickly but causes more pulmonary complications than plasmalyte. The
impact on renal functions was also modest. These effects did not result in improvement
in survival at 28 days. Plasmalyte is safer and well-tolerated and can be considered
for volume resuscitation in patients with cirrhosis and sepsis-induced hypotension.