Análise crítica do uso de albumina humana em pacientes cirróticos descompensados e mortalidade intra-hospitalar: um estudo retrospectivo multicêntrico

Abstract

Cirrhosis is the final stage of any chronic liver disease and its natural history is characterized by an asymptomatic (compensated) phase, which evolves into a decompensated phase. In the decompensated phase, complications such as ascites, gastrointestinal bleeding and hepatic encephalopathy occur, and human albumin (HA) is frequently used in the treatment of these patients. Currently, international guidelines support the use of HA in 4 situations: (1) after large-volume paracentesis (≥ 5 L), (2) in the treatment of hypovolemic acute renal failure, (3) in the diagnosis and treatment of hepatorenal syndrome (HRS) and (4) in the treatment of spontaneous bacterial peritonitis (SBP). Several studies have evaluated HA prescriptions in hospitals and have shown that it is frequently prescribed without indication and outside of protocols. Objectives: to evaluate the impact of inappropriate HA prescriptions on in-hospital mortality of decompensated cirrhotic patients; to describe the use of HA in patients with decompensated cirrhosis admitted to a hospital environment, assessing whether its prescription follows the formal indications recommended in the specialized literature; to evaluate the in-hospital mortality rate of decompensated cirrhotic patients, discussing possible predictors that may have contributed to death, focusing on the inadequate prescription of HA. Methods: a retrospective observational study (review of medical records), multicenter (three brazilian hospitals), creating an unified database from three prospective studies that occurred in each of the centers. Eight patients were excluded (hospitalizations of less than 48 hours or CHILD A). The 61 variables were analyzed in descriptive tables, followed by Logistic Regression with bivariate and multivariate analysis. Results: 123 patients were analyzed; the majority used HA during hospitalization (62.5%) and did so with the correct indication (89.7%). However, only a minority of patients used HA at the recommended dose and time (21% of those who used it). In the multivariate analysis, adjusted by MELD-Na, the use of HA outside the protocol, both at higher or lower doses than recommended, was independently associated with increased in-hospital mortality. Conclusion: despite its beneficial effects, HA is a medication and is associated with adverse events, and should be used according to the indications recommended in the literature. Physicians appear to have good knowledge about the indications for HA use, but do not follow the recommended doses and times of use; this inappropriate prescription appears to negatively impact in-hospital mortality of decompensated cirrhotic patients (both at higher and lower doses).