NHS FORTH VALLEY

Guidelines for Use of Human Albumin Solution

Approved
Version
Date of First Issue
Review Date
Date of Issue
EQIA
Author / Contact

24/01/10
2.3
09/06/2008
30/06/2016
01/07/2014
Yes
Dr Christopher Brammer, Consultant Haematologist

Group / Committee
Final Approval

NHS Forth Valley Hospital Transfusion Committee

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1st July 2014

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NHS Forth Valley

Consultation and Change Record
Contributing Authors:

Consultation Process:

Distribution:

Dr David Watts
Dr Christopher Brammer
Dr Martyn Hawkins
Mr Stephen McBurney
Members of Hospital Transfusion Team; Hospital Transfusion
Committee; Consultant Gastroenterologists; Intensive Care
Consultants

Intranet

Change of Record
Date
Author
23.6.09 Dr C
Brammer

Nature of Change
Removal of reference to 500ml units of
4.5% HAS replacing with 500ml units of
4% HAS.

Reference
Pages 4 and 5

Change to ordering procedure for HAS

to reflect change from stock holding in
Blood Bank to Pharmacy.

Page 6

Removal of reference to Human

Albumin Solution 4.5% 100ml

Page 6

1.6.11

Dr C
Brammer

Removal of any reference to 4% HAS

and replacement with 5% HAS.

Pages 4, 5 and 6

1.3.12

Dr C
Brammer

References to SRI removed and

changed to FVRH.

Page 6

Change to SBP management HAS

now given for confirmed SBP even if
serum creatinine not rising.

Page 5

18.5.12 Dr C
Brammer

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Forth Valley Guidelines for the Usage of Human Albumin Solution (HAS) in
the context of the clinical complications of chronic liver disease

Ascites and large volume paracentesis

o Ascites complicates 50% of all cirrhotic chronic liver disease over
any 10 year period and this occurs typically in the setting of
significant portal hypertension and salt and water retention (largely
unrelated to plasma albumin)
o The onset of ascites in a patient with chronic liver disease is
associated with significant mortality (50% over 2 years)
o Common causes of chronic liver disease include:

viral hepatitis
alcoholic liver disease
autoimmune liver disease e.g. PBC / PSC
haemochromatosis
NASH

o Where management of ascites is refractory to sodium restriction

(90mmol / day) and diuretic Rx large volume paracentesis is often
required.
o Beyond paracentesis, there is a resulting fall in pulmonary capillary
wedge pressure (PCWP) which is maximal at 6 hours. This fall in
PCWP without fluid replacement results in circulatory and renal
dysfunction and is inversely associated with survival.
Guidance for fluid replacement in large volume paracentesis:
1. Where there is normal premorbid renal function:
1 unit (100ml) HAS 20% (STAT) following every 3 litres of ascites
drained.
2. Where renal function is impaired consider either:
a. 100ml HAS 20% per 2 litres of ascites
or
b. adherence to protocol for hepatorenal syndrome (see below)

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Spontaneous bacterial peritonitis (SBP)

SBP is a common complication (10 30%) of hospitalized patients

with ascites due to chronic liver disease and requires prompt
diagnosis and initiation of appropriate antibiotic Rx (ceftriaxone /
ciprofloxacin)

SBP will recur in 70% of patients over a 12 month period

Renal impairment occurs in 30% of patients with SBP

Development of renal failure is a strong predictor of mortality

Administration of HAS in SBP reduces the incidence of renal failure

and mortality

Guidance for Human Albumin Solution in SBP:

For treatment of confirmed SBP:

Day 1: 1.5g HAS / kg given over initial 6 hour period:

Day 3: 1g HAS / kg

E.g. for 80 kg man:

Day 1: 120g albumin

6 units (600ml) 20% HAS (20g / 100ml)

Or

6 units (2500ml) 5% HAS (20g / 500ml)

Day 3: 80g albumin

4 units (400ml) 20% HAS (20g / 100ml)

Or

Version 2.3

4 units (1500ml) 5% HAS (20g / 500ml)

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Hepatorenal syndrome (HRS)

o HRS refers to acute renal failure that occurs in the setting of
cirrhosis or fulminant liver failure associated with portal
hypertension, usually in the absence of other disease of the
kidney.[1][2]
o The pathology involved in the development of hepatorenal
syndrome is thought to be an alteration in blood flow and blood
vessel tone in the circulation that supplies the intestines (the
splanchnic circulation) and the circulation that supplies the kidney.[3]
o It is usually indicative of the end-stage of pathologically reduced
perfusion, or blood flow to the kidney, due to deteriorating liver
function.
o Occurs in up to 10% patients with cirrhotic liver disease
o Hepatorenal syndrome is associated with high mortality and, if
untreated, the condition is usually fatal.
o Treatment usually involves medical therapy or TIPS as a bridge to
liver transplantation.[2]
o Administration of HAS and vasoconstrictors are effective Rx in 60%
of patients with HRS and associated with improved survival

Guidance for medical Rx in HRS:

1. Terlipressin: 0.5 2mg IV every 4 hours
2. Human albumin solution:
a . Day 1: 1g / kg HAS
Either 20% HAS (20g /100ml) or 5% HAS (20g/500ml)
b . Day 2 - 16: 20 40 g HAS / day
Rx continued until serum creatinine falls below 130mol/l
NB. Where creatinine is rising despite Rx, 60g HAS /day may be
clinically indicated

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Requesting Human Albumin Solution:

Human Albumin Solution (HAS) is available from the Hospital Pharmacy at Forth
Valley Royal Hospital (FVRH) and is issued on a named patient basis to comply
with UK blood transfusion guidelines and UK/EU Good Manufacturing Practice
regulations.
The products in stock are:
Human Albumin Solution 5.0% 500ml (approx 20g albumin)
Human Albumin Solution 20% 100ml (approx 20g albumin)

For all the indications detailed above, clinical guidance is provided by the
Consultant Gastroenterologists, who will indicate which of the above products,
and how much, is required for each individual patient. Medical staff responsible
for the care of the patient should then request HAS directly from the FVRH
Pharmacy department by completing a pharmacy indent request, available on the
ward, with the following information:
Full name, date of birth and CHI number for the patient
Product required and volume (number of bottles) to be issued
Location of patient and time when HAS is required
For all indications not included in these guidelines, the request will be redirected
to the duty consultant haematologist for authorization. The Hospital Transfusion
Committee will monitor and audit HAS issue and use.
HAS will be issued from the pharmacy on a daily basis as required it is not
appropriate to store HAS in the ward area. A small emergency stock of HAS will
be held in ITU and the Pharmacy dept. emergency fridge (which the bed coordinator has access to). At the end of the clinical episode, any HAS which has
not been infused to the named patient must be destroyed as clinical waste. It is
not acceptable to infuse a product issued to a named patient into any other
individual.
References:
1.Arroyo V, Gines P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, Reynolds TB,
Ring-Larsen H, Scholmerich J. Definition and diagnostic criteria of refractory
ascites and hepatorenal syndrome in cirrhosis. International Ascites Club.
Hepatology. 1996 Jan; 23(1):164-76.
2. Wong F, Blendis L. New challenge of hepatorenal syndrome: prevention and
treatment. Hepatology 2001 Dec; 34(6):1242-51.
3. Arroyo V, Guevara M, Gines P. Hepatorenal syndrome in cirrhosis:
pathogenesis and treatment. Gastroenterology 2002 May; 122(6):1658-76.

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Further references:
British Society of Gastroenterology Guidelines for the management of ascites
in cirrhosis. Gut 2006
http://www.bsg.org.uk/bsgdisp1.php?id=6831b1e0bcbd40a30f82&h=1&sh=1&i=1
&b=1&m=00023
Gines et al. The management of ascites in adult patients with cirrhosis.
N Engl J Med. 2004 Apr 15; 350(16):1646-54.
Runyon BA et al Management of adult patients with ascites caused by cirrhosis
Hepatology. 1998 Jan; 27(1):264-72.
Runyon BA American Association for Study of Liver Disease Practice
Guideline. Management of adult patients with ascites due to cirrhosis
Hepatology 2004 39(3):1-16
https://www.aasld.org/eweb/docs/practiceguidelines/ascites.pdf

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Publications in Alternative Formats

NHS Forth Valley is happy to consider requests for publications in other
language or formats such as large print.
To request another language for a patient, please contact 01786 434784.
For other formats contact 01324 590886,
text 07990 690605,
fax 01324 590867 or
e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net

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