High Dose Albumin in Refractory Ascites

Clinical Efficacy of High-dose Albumin Administration Versus Standard Dose in Patients With Advanced Cirrhosis: Open Label Randomized Clinical Trial

Advanced cirrhosis with complications is a serious problem imposing a heavy financial burden on health care system. Moreover, ascites is associated with increase in mortality rates among cirrhotic patients. Ascites pathogenesis is multifactorial including: portal hypertension; splanchnic and peripheral arterial vasodilation; and neurohumoral activation. Current management strategies include dietary sodium restriction and diuretic therapy, however, this strategy put patients at the risk of intravascular volume depletion, renal impairment, hepatic encephalopathy and hyponatremia. Moreover, around 10% of patients do not respond to this strategy (termed: diuretics resistant) with 50% of them die within 6 months. This sub-group is managed by frequent large volume paracentesis along with intravenous albumin administration and are usually considered for liver transplantation (LT) and TIPS. Nonetheless, Frequent paracentesis increases the risk of infection, bleeding, bowel perforation, paracentesis-induced circulatory dysfunction (PICD) and renal dysfunction in this sub-group of patients. The beneficial effect of human albumin might result from blood volume expansion tapering activated vasoconstrictor and sodium-retaining systems improving renal perfusion, hence regular infusion of albumin may be beneficial to prevent development of ascites and to improve survival. The positive effects of albumin are supported by previous studies; Romanelli et al, showed a significant increase in survival rate among cirrhotic patients with ascites when compared to those who did not receive albumin. Moreover, a randomized multicenter open label trial published in lancet last year, demonstrated that long term albumin administration improved 18-month survival, decreased the use of paracentesis and decrease in the incidence of cirrhosis related complications among cirrhotic patients with ascites. As of today, there's a limited use of regular high dose albumin in cirrhotic patients with ascites in US, despite being used elsewhere in the world as previously stated.

The investigators wish to study long-term efficacy of human albumin administration in patients with decompensated cirrhosis to assess safety and efficacy, and prevention of complications of cirrhosis.

Study Overview

• Status: Recruiting
• Conditions: Ascites
• Intervention / Treatment: Drug: Albumin

Detailed Description

Patients with advanced liver disease often has low serum albumin level. The Infusion of human albumin is a standard of care after removal of ascitic fluid in patients with cirrhosis with refractory ascites. The objective of the study is to prove that regular infusion of albumin prevents formation of fluid in abdomen (ascites) or pleural fluid (Hydrothorax) and thus reduces the requirement of paracentesis or thoracentesis, and prevent complications.

The Primary endpoints are: (1) Number of paracentesis/thoracentesis needed and volume of fluid removed per month and if there is any reduction in frequency or volume after high-dose albumin administration; (2) Twelve-month mortality or transplant. Secondary endpoints are: (1) Improvement of MELD score; (2) Cumulative diuretic dosage; (3) Development of hyponatremia or hyperkalemia as potential diuretic-induced side-effects; (4) Incidence of cirrhosis related complications (spontaneous bacterial peritonitis, other bacterial infections, renal impairment, hepatorenal syndrome, hepatic encephalopathy and gastrointestinal bleeding related to portal hypertension); (5) Quality of life; (6) Number and duration of hospital admissions; and (7) Treatment cost-effectiveness.

The research design is a prospective, parallel, randomized, open label clinical trial. The target trial population comprises of patients with advanced cirrhosis. Eligible patients will be randomized into either one of two categories: 1) the control group will receive the standard of care (SOC) including moderate sodium restriction and maximal daily tolerated doses of diuretics, and 2) the Intervention group will receive intravenous human albumin at a dose (1g/kg, with minimum dose of 50g and maximum dose of 100g) weekly plus SOC.

In both groups, when large-volume paracentesis is needed, the patient will receive human albumin in the dose of 6-8 g/L of ascites removed as SOC.

Inclusion Criteria:

1. Age > 18 years.
2. patients diagnosed with liver cirrhosis. Refractory ascites which is defined as ascites failing to resolve after maximum tolerable dose of diuretics, and usually require frequent paracentesis.

Exclusion Criteria:

1. Patients < 18y and patients with no history of liver cirrhosis
2. patients with refractory ascites but have trans-jagular intrahepatic portosystemic shunts (TIPS) with previous 3 months
3. Patients with ascites due to other causes, including cardiac, malignant Procedure Eligible patients will be identified by the PI and the research team. Participants will be approached to participate in the study. The research coordinator will fully explain the study procedures, and if the patient is willing to participate, he or she will sign the informed consent. After signing the informed consent, eligible patients will be randomly assigned into two groups: 1) the control arm will receive the standard of care (SOC), including moderate sodium restriction, maximal daily tolerated doses of diuretics, and post-paracentesis albumin, and 2) the intervention group will receive intravenous human albumin at a dose of (1g/kg), with a minimum dose of 50g and a maximum dose of 100g, plus SOC. patients will be randomly assigned (1:1) to either of these two groups.

In both groups, when large-volume paracentesis is needed, the participant will receive human albumin in the dose of 6-8 g/L of ascites removed.

No concomitant medications are withheld during the study. After enrollment, participants will be assessed by a physician monthly for up to one year or study interruption or liver transplant or death. In both groups with refractory ascites, most of the patient require weekly or biweekly monitoring and paracentesis. The investigators plan to approach the patients during these visits to get the consent and administer the extra albumin dose.

In each visit, ascites severity will be evaluated with hemodynamic status, weight, new symptoms, and diuretic dose. Each visit may last 15 minutes or more.

Patients who consent to the study will complete a self-administered questionnaire to assess health-related quality of life (using CLDQ, CLDQ-HCV and CLDQ- NASH Questionnaires). Each patient response will be coded to ensure privacy, and the coded data will be entered into a collection sheet with no protected health information (PHI) gathered during the survey. The investigators will give the questionnaire: at the time of enrollment and at the 6 and 12 month time points

• Study Type: Interventional
• Enrollment (Estimated): 100
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Prasun Jalal, MD; Phone Number: 8323551424; Email: jalal@bcm.edu

Study Locations

• United States
  • Texas
    • Houston, Texas, United States, 77030
      • Recruiting
      • Baylor St' Lukes Medical center
      • Principal Investigator: Prasun K Jalal, MD
      • Contact: Prasun K Jalal, MD; Phone Number: 8323551424; Email: jalal@bcm.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Age > 18 years.
2. patients diagnosed with liver cirrhosis.
3. Refractory ascites which is defined as ascites failing to resolve after maximum tolerable dose of diuretics, and usually require frequent paracentesis.

Exclusion Criteria:

1. Patients < 18y
2. patients with no history of liver cirrhosis
3. patients with refractory ascites but have transjagular intrahepatic portosystemic shunts (TIPS) with previous 3 months
4. Patients with ascites due to other causes, including cardiac, malignant

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention arm; the intervention group will receive intravenous human albumin at a dose of (1g/kg), with a minimum dose of 50g and a maximum dose of 100g, plus SOC	Drug: Albumin; intravenous human albumin at a dose of (1g/kg), with a minimum dose of 50g and a maximum dose of 100g; Other Names: High dose albumin (HA)
No Intervention: Control arm; the control arm will receive the standard of care (SOC), including moderate sodium restriction, maximal daily tolerated doses of diuretics, and post-paracentesis albumin

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of large volume paracentesis needed	Number of paracentesis/thoracentesis needed.	1 year
The volume of fluid removed in liters per after high-dose albumin administration	Measuring the fluid amount removed each paracentesis and compare it to before High dose albumin administration	1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of cirrhosis related complications (spontaneous bacterial peritonitis, other bacterial infections, renal impairment, hepatorenal syndrome, hepatic encephalopathy and gastrointestinal bleeding related to portal hypertension).	Each attack of decompensation will be documented during enrollment. We will compare number of decompensation episodes in each group	1 year
Diuretics dosage assessment	Trend for Dosage of diuretics required in mg during the enrollment period.	1 Year
Liver related quality of life assessment.	Liver related quality of life assessment.	1 year
Mortality at 1 year after enrollment	Twelve-month mortality	1 year
Number and duration of hospital admissions	Number of visits to ER, hospital admissions will also be assessed	1 year
Treatment cost-effectiveness.	Cost of albumin vs cost of paracentesis and paracentesis related hospitalizations	1year

Collaborators and Investigators

• Sponsor: Baylor College of Medicine
• Investigators: Principal Investigator: Prasun Jalal, MD, Baylor College of Medicine

Publications and helpful links

General Publications

• Romanelli RG, La Villa G, Barletta G, Vizzutti F, Lanini F, Arena U, Boddi V, Tarquini R, Pantaleo P, Gentilini P, Laffi G. Long-term albumin infusion improves survival in patients with cirrhosis and ascites: an unblinded randomized trial. World J Gastroenterol. 2006 Mar 7;12(9):1403-7. doi: 10.3748/wjg.v12.i9.1403.
• Gines P, Quintero E, Arroyo V, Teres J, Bruguera M, Rimola A, Caballeria J, Rodes J, Rozman C. Compensated cirrhosis: natural history and prognostic factors. Hepatology. 1987 Jan-Feb;7(1):122-8. doi: 10.1002/hep.1840070124.
• Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut. 2006 Oct;55 Suppl 6(Suppl 6):vi1-12. doi: 10.1136/gut.2006.099580. No abstract available.
• Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther. 2005 Mar 1;21(5):525-9. doi: 10.1111/j.1365-2036.2005.02387.x.
• Di Pascoli M, Ceranto E, De Nardi P, Donato D, Gatta A, Angeli P, Pontisso P. Hospitalizations Due to Cirrhosis: Clinical Aspects in a Large Cohort of Italian Patients and Cost Analysis Report. Dig Dis. 2017;35(5):433-438. doi: 10.1159/000458722. Epub 2017 Mar 1.
• Schmidt ML, Barritt AS, Orman ES, Hayashi PH. Decreasing mortality among patients hospitalized with cirrhosis in the United States from 2002 through 2010. Gastroenterology. 2015 May;148(5):967-977.e2. doi: 10.1053/j.gastro.2015.01.032. Epub 2015 Jan 23.
• Pedersen JS, Bendtsen F, Moller S. Management of cirrhotic ascites. Ther Adv Chronic Dis. 2015 May;6(3):124-37. doi: 10.1177/2040622315580069.

Study record dates

Study Major Dates

• Study Start (Actual): March 25, 2019
• Primary Completion (Estimated): March 25, 2026
• Study Completion (Estimated): June 25, 2026

Study Registration Dates

• First Submitted: April 20, 2023
• First Submitted That Met QC Criteria: May 10, 2023
• First Posted (Actual): May 22, 2023

Study Record Updates

• Last Update Posted (Estimated): September 29, 2025
• Last Update Submitted That Met QC Criteria: September 24, 2025
• Last Verified: September 1, 2025

More Information

Terms related to this study

• Keywords: liver cirrhosis; refractory ascites; HRS; High dose albumin
• Additional Relevant MeSH Terms: Pathologic Processes; Digestive System Diseases; Liver Diseases; Fibrosis; Pathological Conditions, Signs and Symptoms; Liver Cirrhosis; Ascites; Amino Acids, Peptides, and Proteins; Proteins; Albumins
• Other Study ID Numbers: H-49043

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No