A randomized-controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsisinduced hypotension [ALPS trial]

Abstract

Sepsis is an inflammatory response to severe infection characterized by hypovolemia and vasodilation.1 It is characterized by organ dysfunction secondary to a dysregulated immune response of the host to the microbial pathogen. Prompt identification, early institution of appropriate antibiotics, and fluid resuscitation can improve patient outcomes.1 Hypoperfusion is a hallmark in patients with sepsis-induced hypotension seen secondary to the increase in oxygen demand and decrease in oxygen delivery to the peripheral tissues causing organ dysfunction.2 Early and appropriate fluid resuscitation is crucial for improving patient outcomes in sepsis. Patients with cirrhosis and sepsis are a distinct group.1 The hemodynamic alterations are more profound in patients with cirrhosis with sepsis compared to those without cirrhosis. The choice of fluid, i.e. crystalloid vs. colloid and balanced vs. non-balanced, is controversial.3 Patients with advanced cirrhosis have effective hypovolemia, hypoalbuminemia, and splanchnic and systemic vasodilatation. These hemodynamic alterations get exacerbated with sepsis.1,3 Patients with cirrhosis, in addition, have impaired responsiveness to endogenous and exogenous vasoconstrictors. The resultant arterial pooling of blood increases blood volume in the splanchnic circulation. Reduced central blood volume is responsible for a decreased preload and less than expected cardiac output, which compromises renal perfusion and causes sodium and water retention.