Point-of-care ultrasound of the inferior vena cava for intravascular volume assessment during intravenous albumin infusion in patients with cirrhosis.

Background & Aims Current guidelines recommend intravenous (i.v.) albumin for different indications in decompensated cirrhosis, but iatrogenic hypervolemia following i.v. albumin is increasingly reported. We aimed to characterize intravascular volume status using point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) during passive leg raise (PLR) and i.v. albumin, potentially facilitating clinical management and adjustment of albumin dosage.Methods This prospective pilot cohort included patients with decompensated cirrhosis requiring i.v. albumin. We assessed changes in minimal and maximal IVC diameters (IVCmin and IVCmax, respectively) and collapsibility index (IVCCI) during PLR and after i.v. albumin. We defined severe intravascular volume overload as IVCmax >2.1 cm and IVCCI <20%. Clinical outcomes were recorded until 3 months after POCUS.Results We included 81 measurements in 55 patients (70.9% men; median age 62 years; 58.2% alcohol-related cirrhosis; median Child-Pugh score 9 points; 89.1% paracentesis; median 40 g i.v. albumin; 5.5 L ascites). We found a significant increase in IVC diameters both during PLR (change in mean [Δ] IVCmin +20.7%, Δ IVCmax +14.1%, p <0.01) and after i.v. albumin (Δ IVCmin +58.8%, Δ IVCmax +48.2%, p <0.01). There was a significant decrease in IVCCI during PLR (relative Δ -11.1%, p <0.01) and after i.v. albumin (relative Δ -18.0%, p <0.01). Potential severe intravascular volume overload occurred on 17 occasions (21%) after i.v. albumin, more frequently in women than in men (40% vs. 15.7%, p <0.01), and showed higher cumulative incidence rates in variceal bleeding after 1 (16.7% vs. 0%, p = 0.01) and 3 months (18.2% vs. 0%, p = 0.01).Conclusions Potential severe intravascular volume overload after i.v. albumin was detected in every fifth patient with decompensated cirrhosis. Thus, there is a need to develop strategies for individualizing volume management in patients with decompensated cirrhosis.Impact And Implications Iatrogenic volume overload after albumin infusions in patients with cirrhosis is a potentially harmful side effect, but no policy for monitoring intravascular volume overload using non-invasive tools has been suggested so far. New-onset potential volume overload was detected in almost one out of five men and four out of 10 women and was associated with increases in N-terminal prohormone of brain natriuretic peptide, lower mean arterial pressure during albumin infusion, and higher serum sodium levels. Our results from this proof-of-concept study emphasize the need for larger prospective cohort studies to validate our findings and introduce strategies for individualizing volume management in patients with decompensated cirrhosis.