Patients with cirrhosis and ascites treated with long-term albumin: An integrated management proposal based on a real-life study

Background and Aims Long-term albumin (LTA) is widely used in Italy in patients with cirrhosis and ascites. This study aims to analyze clinical courses and outcomes of patients receiving LTA. Methods Secondary analysis of “Real-ANSWER”, an Italian multicenter, retrospective, real-world study. Results Of the 312 patients included (median Child-Pugh 8, MELD 15), after 3 months of LTA, 34% resolved ascites to grade 0-1 (responders), 33% had persistent ascites but no need for paracentesis (partial responders) and 33% still received paracentesis to control ascites (non-responders). At baseline, non-responders had more severe ascites, higher white blood cell count (6.00 vs 4.80 vs 4.90 109/L, p=0.001) and creatinine (1.1 vs 0.9 vs 0.9 mg/dl, p=0.003) compared to other groups, while no differences were found in etiology of cirrhosis, serum albumin, MELD and Child-Pugh. Among responders, 40% discontinued LTA due to improvement (median: 7 months; IQR 4-12), 26% received a transplant, 15% died. Among non-responders, 18% received TIPS (median: 5 months; IQR 3-12), 33% died, 11% received a transplant. Interestingly, 15% discontinued LTA due to subsequent improvement (median: 14 months; IQR 10-22), half of whom received etiological treatments. Among partial responders, 16% discontinued LTA due to improvement (median: 10 months; IQR 5-22), 21% received a transplant and 42% died. The cumulative incidence of 18-month mortality was lower in responders (18%) compared to partial responders (46%) and non-responders (42%, p<0.001). Conclusion Based on the ascites response after 3 months of LTA, three categories with different clinical courses can be identified, which would help in the decision-making process. Non-responders should receive TIPS whenever possible, except for those undergoing effective etiological treatment who can be reassessed later. Responders should continue with LTA as they have the highest chance of survival, resolution of ascites and likely recompensation. Treatment should be tailored on a case-by-case basis in partial responders.