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Albumin - Adult - Inpatient

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Albumin – Adult – Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 4
METHODOLOGY .................................................................................................................... 4
DEFINITIONS.......................................................................................................................... 5
INTRODUCTION ..................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 5
UW HEALTH IMPLEMENTATION ........................................................................................... 12
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 13
REFERENCES ........................................................................................................................ 14
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Contact for Content:
Name: Sara Shull, PharmD - Pharmacy
Phone Number: (608) 262-1817
Email Address: ssmith-shull@uwhealth.org

Contact for Changes:
Name: Philip Trapskin, PharmD - Pharmacy
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org

Guideline Author(s):
Jeff Fish, PharmD- Pharmacy
Eileen Shannon, PharmD- Pharmacy
Sara Shull, PharmD - Pharmacy

Coordinating Team Members:
Sara Shull, PharmD– Pharmacy

Review Individuals/Bodies:
Aimee Becker, MD- Anesthesia
Bartho Caponi, MD- Hospital Medicine
Caitlin Curtis, PharmD- Pharmacy
Anthony D’Alessandro, MD- Transplant Surgery
Arjang Djamali, MD- Nephrology
Lee Faucher, MD- Trauma Surgery
Jeff Fish, PharmD- Pharmacy
David Foley, MD- Transplant Surgery
David Hager, PharmD - Pharmacy
Hee Soo Jung, MD- Trauma Surgery
Dixon Kaufman, MD- Transplant Surgery
Jonathan Ketzler, MD- Anesthesia
Pierre Kory, MD- Pulmonary Medicine
James Maloney, MD- Cardiothoracic Surgery
Didier Mandelbrot, MD- Nephrology
Josh Medow, MD- Neurosurgery
Jon Odorico, MD- Transplant Surgery
Ann O’Rourke, MD- Trauma Surgery
Marie Pietruszka, PharmD - Pharmacy
John Rice, MD- Gastroenterology
Sara Shull, PharmD, MBA - Pharmacy
Philip Trapskin, PharmD - Pharmacy
Jeffery Wells, MD- Pulmonary Medicine
David Yang, MD- Clinical Laboratory
Alexander Yevzlin, MD- Nephrology

Committee Approvals/Dates:
Pharmacy & Therapeutics Committee (Last Periodic Review: August 2013, July 2017)

Release Date: July 2017 | Next Review Date: July 2019


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Executive Summary
Guideline Overview
This guideline provides recommendations for the therapeutic use of albumin to treat several
common disorders in the inpatient setting. Individual clinician experience may suggest stronger
recommendations for some indications. However evidence based conclusions are derived from
the currently available evidence.

Key Practice Recommendations
1. Albumin is recommended for the diagnosis and treatment of Type 1 hepatorenal syndrome
with cirrhosis
2. Albumin is recommended for the treatment of spontaneous bacterial peritonitis with cirrhosis
in conjunction with appropriate antimicrobial therapy
3. Repletion with albumin is recommended after large volume paracentesis in cirrhosis and
after plasmapheresis
4. General use of albumin to treat all patients with sepsis is not recommended, however
albumin may be considered for the treatment of septic and hemorrhagic shock following
failure of isotonic crystalloid fluids.
5. Albumin may be considered in patients that are edematous but intravascularly depleted and
with a plasma albumin < 2 g/dL. Examples populations include patients with cirrhosis that
have ascites that is unresponsive to diuretics and who are not undergoing paracentesis OR
patients who have undergone major surgery (e.g. > 40% hepatic resection or extensive
intestinal resection).
6. Use of albumin may be considered to treat burns when appropriate administration of
crystalloid fluid does not result in minimum urine output.
7. Albumin may be considered to treat volume depletion following liver transplant.
8. Albumin may be considered for treatment of hypo-oncotic shock in patients with acute
respiratory distress syndrome
9. Albumin may be considered to treat nephrotic syndrome
10. Albumin may be considered to treat symptomatic hypotension during hemodialysis.
11. Albumin should not be administered to patients with traumatic brain injury and should be
administered with care in the setting of other traumas.

Companion Documents
1. Diagnosis and Management of Sepsis- Adult- Emergency Department/ Inpatient Clinical
Practice Guideline
2. Intravenous Administration of Formulary Medications – Adult – Inpatient/ Ambulatory Clinical
Practice Guideline
3. Parenteral Nutrition – Adult - Inpatient/ Ambulatory Clinical Practice Guideline


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Scope
Disease/Condition(s): Cirrhosis, hepatorenal syndrome, spontaneous bacterial peritonitis,
extracorporeal membrane oxygenation, septic shock, hemorrhagic shock, burns, volume
depletion/ expansion, cardiac surgery, liver transplantation, nephrotic syndrome, acute lung
injury/ acute respiratory distress syndrome, hemodialysis

Clinical Specialty: The following clinical specialties may use this guideline: Critical Care,
Hospital Medicine, Pulmonology, Surgery, Transplantation, Hepatology, Nephrology,
Cardiology, Trauma, Infectious Disease, Anesthesia, and Nutrition Support

Intended Users: Physicians, Advanced Practice Providers, Nurses, Nutrition Support,
Pharmacists, Technical Support

Objective(s): To provide evidence-based recommendations to assist clinicians in determining
the benefits of albumin use in patients with relevant disorders.

Target Population: All adult inpatients cared for within UW Health who have a disorder for
which albumin may be appropriate treatment

Interventions and Practices Considered: Albumin is the sole clinical intervention considered
in the guideline, sometimes as a second or third line therapy

Major Outcomes Considered:
ξ Mortality
ξ Blood pressure
ξ Fluid balance
ξ Plasma albumin level
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
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Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Cost Analysis: No formal cost analysis was done to direct the recommendations made in this
guideline.

Recognition of Potential Health Care Disparities: Insofar as care for the disorders described
above is initiated, there are no recognized health care disparities when administering albumin.
Definitions
Extracorporeal membrane oxygenation: a modified form of cardiopulmonary bypass to support
both cardiac and pulmonary function

Cirrhosis: a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic
architecture and the formation of regenerative nodules

Hepatorenal syndrome: functional renal failure associated with advances cirrhosis. The
diagnosis includes cirrhosis and ascites plus impaired renal function after exclusion of
parenchymal renal disease

Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection

Spontaneous bacterial peritonitis: an ascitic fluid infection without an evident intra-abdominal
surgically treatable source.
Introduction
Albumin is a protein-based colloid therapy used in fluid resuscitation for hypovolemic states associated
with various conditions and for correcting hypoalbuminemia in circumstances of specific symptomatology.
The major indication for use of albumin therapy is volume expansion. Other classes of agents used to
manage hypovolemic states include crystalloid fluids. Albumin is substantially more expensive than
crystalloid fluids. A Cochrane review evaluated 74 randomized controlled trials comparing the use of
colloid to crystalloid therapy for volume replacement in critically ill patients and found no evidence of
decreased mortality with colloid use over crystalloids.1 Meanwhile, a prospective cohort study in a
surgical ICU demonstrated that implementing albumin use guidelines decreased albumin use by 54%.2
The restrictive use of albumin had no negative impact on ICU mortality, but resulted in a 56% reduction in
cost. This demonstrates that evidence based recommendations organized in guidelines endorsed by
stakeholders can increase the probability of deriving optimal value from albumin. General guidelines for
the use of albumin are available in the published literature3-6 and were consulted in the creation of this
guideline. The recommendations established in this guideline reflect current evidence and local expert
opinion.

Recommendations

Albumin administration is recommended for the following indications

1. Management of hepatorenal syndrome (HRS) / acute kidney injury (AKI) in patients with
cirrhosis and probable non-structural injury (i.e. pre-renal azotemia).
a. Establish differential diagnosis7,8
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i. Use of albumin as fluid challenge is recommended. (UW Health low
quality evidence; strong recommendation)
1. When patient is clinically volume depleted
a. Albumin type: 5%
b. Dose until clinical volume repletion is achieved- suggested
initial dose is 12.5 - 25 g (250- 500 mL)
2. When there is no evidence of obvious volume depletion
a. Albumin type: 25%
b. Dose: 1 g/kg per day for 2 days
i. Maximum daily dose: 100 g (400 mL)
ii. Assess for resolution or progression of AKI at 48 hours after initiating
albumin therapy

b. Treatment of Type 1 HRS with albumin in patients with cirrhosis is
recommended. (UW Health high quality evidence; strong recommendation)3,5,6,9-11
i. Albumin type: 25%
ii. Dose: 1 g/kg on day 1
1. Maximum daily dose: 100 g (400ml)
iii. Suggested subsequent daily dose is 25 g/day (100ml)
iv. Must be given in combination with octreotide and midodrine with a goal
to increase mean arterial pressure by at least 15 mm Hg from baseline6
1. Octreotide dose: Initially, 100 mcg subcutaneously 3 times per
day; titrate to 200 mcg subcutaneously 3 times per day
2. Midodrine dose: Initially 5-10 mg orally 3 times per day; titrate to
12.5 mg orally 3 times per day OR
v. Alternatively a norepinephrine drip, titrated to appropriate dose, may be
used for vasoconstriction in combination with albumin if the patient
resides in an intensive care unit.
vi. The following duration of therapy for albumin is recommended.3
1. In patients that respond to vasoconstrictors and albumin as
evidenced by a decrease in plasma creatinine, discontinue
albumin when plasma creatinine has returned to or is close to
baseline, or has not decreased further after 3 days of treatment
2. In patients that do not respond to vasoconstrictors and albumin,
discontinue albumin after a maximum of 7 days
3. Discontinue albumin if patient is started on renal replacement
therapy or the plasma albumin level is > 3 g/dL.

2. Treatment of spontaneous bacterial peritonitis (SBP) with albumin in patients with
cirrhosis is recommended.3,10,12,13 (UW Health moderate quality evidence; strong
recommendation)
a. Albumin type: 25%
b. Dose: 1.5 g/kg on day 1, followed by 1 g/kg on day 3
i. Maximum daily dose: 100 g (400 mL)
c. Albumin should be given with appropriate antibiotics

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3. For large volume serial paracentesis (>4 L) in patients with ascites due to cirrhosis and
without infection, an albumin infusion of 6 g per liter of ascitic fluid removed is
recommended due to improved survival.3,6,14 (UW Health high quality evidence; strong
recommendation)
a. Albumin type: 25%
b. Dose: Albumin dose is 6 g per liter of ascitic fluid removed6
i. For ≤ 3 liters, do not administer albumin
ii. For 4 liters, administer 25 g (100 mL)
iii. For 5-6 liters, administer 37.5 g (150 mL)
iv. For 7-8 liters, administer 50 g (200 mL)
v. For 9-10 liters, administer 62.5 g (250 mL)
vi. For 11-12 liters, administer 75 g (300 mL)
vii. For 13-14 liters, administer 87.5 g (350 mL)
viii. For 15-16 liters, administer 100 g (400 mL)

Volume Removed (liters) Albumin Dose (grams)
≤ 3 Do not administer albumin
4 25
5-6 37.5
7-8 50
9-10 62.5
11-12 75
13-14 87.5
15-16 100

1. Maximum dose: 100 g (400 mL)

4. Volume repletion with albumin following therapeutic large-volume plasmapheresis is
recommended when the following criteria are met.5,15 (UW Health low quality evidence;
strong recommendation)
a. > 20 mL/kg in a single session OR
b. > 20 mL/kg/week in successive sessions
c. Albumin type: 5%
b. Dose: replace 70-80% of plasma volume removed with albumin


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Albumin administration may be considered for the following indications
1. Treatment of shock states with albumin may be considered after failure of crystalloids to
restore adequate fluid volume.16-23 (UW Health moderate quality evidence; weak/
conditional recommendation)
a. Septic shock
i. Crystalloids are recommended as the initial fluid of choice in the resuscitation
of septic shock.23 (UW Health moderate quality evidence; strong
recommendation)
ii. Albumin (5%) may be considered for resuscitation in specific patients with
septic shock that require substantial fluid support in addition to crystalloids to
maintain adequate mean arterial pressure. However, given the high cost of
albumin compared to crystalloid fluid, routine administration of albumin is not
recommended in the setting of septic shock.23 (UW Health low quality
evidence; weak/conditional recommendation)
1. Albumin type: 5%
2. Dose: 12.5 g (250 mL)repeat as needed

b. Hemorrhagic shock1,24 (UW Health moderate quality evidence; weak/conditional
recommendation)
i. Albumin may be considered as last line therapy after crystalloids and blood
products have been used at maximal doses without adequate clinical
response. Albumin administration is contra-indicated in patient with traumatic
brain injury and should be used with care in patients with traumatic injuries.
1. Albumin type: 5%
2. Dose: 12.5 g (250 mL) is suggested: repeat as needed

2. Treatment with albumin may be considered in patients who are edematous but
intravascularly depleted and who have a plasma albumin < 2 g/dL.3,6,25-31 (UW Health
moderate quality evidence; weak/conditional recommendation). Example populations
include:
a. Patients with cirrhosis and ascites which is unresponsive to diuretics but who are
not undergoing paracentesis
b. Patients who have undergone major surgery (e.g. > 40% hepatic resection,
extensive intestinal resection)
i. Albumin type: 25%
ii. Dose: 12.5-25 g (50-100 mL) repeat as needed

3. Albumin may be considered for the treatment of burns when the projected 24hour
crystalloid fluid requirement to achieve urine output of > 0.5 mL/kg/hr exceeds twice the
volume calculated by the Parkland formula. 1,5,32-35 (UW Health low quality evidence; weak/
conditional recommendation)
a. Albumin type: 25%
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b. Dose: Initiate albumin at a rate of 10 mL/hr until crystalloid fluid requirements for
adequate urine output (> 0.5 mL/kg/hr) return to the volume calculated by the
Parkland formula (2-4 mL/kg/% Total Burn Surface Area)

4. Treatment of volume depletion due to cardiothoracic and vascular surgery with albumin may
be considered 5,36,37 (UW Health low quality evidence; weak/ conditional recommendation)
a. For volume expansion during cardiac surgery (in addition to crystalloids)
i. Albumin type: 5%
ii. Dose: 12.5-25 g (250-500ml)
b. For volume expansion following cardiac surgery (in addition to crystalloids)
i. Albumin type: 5%
ii. Dose: 12.5 g (250 mL) is suggested; repeat as needed
c. For priming of the extracorporeal cardiopulmonary bypass circuit37
i. Albumin type: 25%
ii. Dose: 12.5-25 g (50-100ml)
d. For volume expansion necessary when there is large blood loss as a result of
abdominal aortic aneurysm (AAA) or thoracic aortic aneurysm (TAA) repair
i. Albumin type: 5%
ii. Dose: 12.5 g (250 mL) is suggested; repeat as needed

5. Treatment of volume depletion due to liver transplantation with albumin may be
considered38,39 (UW Health low quality evidence/ weak conditional recommendation)
a. Albumin administration is appropriate when plasma albumin is <2.5 g/dL and patient
is determined to be fluid responsive
i. For post-operative control of ascites and peripheral edema
1. Albumin type: 25%
2. Dose: 12.5-25 g (50-100 mL) is suggested: repeat as needed
ii. To replace large volumes of ascitic fluid through drainage tubes
1. Albumin type: 5%
2. Dose: 12.5- 25 g (250 – 500 mL) is suggested; repeat as needed
Consider stopping albumin when drain output is < 500 mL/day

6. Prevention of edema and graft reperfusion injury during and immediately following pancreas
transplant with albumin may be considered for solitary pancreas and simultaneous
pancreas/kidney transplants. (UW Health very low quality evidence; weak/ conditional
recommendation)
a. Albumin type: 25%
b. Dose: 12.5-25 g (50-100 mL) is suggested; repeat as needed

7. Albumin may be considered for the treatment of nephrotic syndrome40-42 (UW Health low
quality evidence; weak/ conditional recommendation)
a. For fluid resuscitation in patients with pulmonary edema and/or acute renal failure,
who have failed to improve on optimal diuretic therapy
i. Albumin administration is appropriate when plasma albumin is < 2 g/dL
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ii. Albumin should be used in conjunction with diuretics
iii. Albumin type: 25%
iv. Dose: 12.5-25 g (50-100 mL) is suggested

8. Albumin may be considered for the treatment of acute lung injury / acute respiratory distress
syndrome43-45 (UW Health moderate quality evidence; weak/ conditional recommendation)
a. Albumin administration is appropriate when the total plasma protein, level is less
than 6 g/dL (note the distinction between total plasma protein and albumin; the
plasma albumin level is not used as criteria for albumin administration in these
disorders)
b. Albumin should be used in conjunction with furosemide
i. Albumin type: 25%
ii. Dose: 25 g (100 mL) IV every 8 hours as needed for 3 days
iii. Discontinue when total plasma protein level is greater than 8 g/dL

9. Albumin may be considered for the treatment of symptomatic hypotension during
hemodialysis46,47 (UW Health moderate quality evidence; weak/ conditional
recommendation)
a. When patient experiences symptomatic hypotension during hemodialysis
b. Albumin administration is appropriate as second line volume expansion after
crystalloid administration
i. Albumin type: 25%
ii. Dose: 12.5-25 g (50-100 ml) every 15 minutes as needed to keep systolic
blood pressure (SBP) above 90 mmHg

10. Albumin may be considered to increase the extracorporeal membrane oxygenation (ECMO)
flow rate when the rate is less than 10% of ordered flow for at least 5 minutes. (UW Health
very low quality evidence; weak recommendation).
a. Albumin type: 25%
b. Dose: 12.5 – 25 g (50 – 100 mL) for each administration

11. Albumin administration may be considered in non-traumatic neurosurgery patients when use
of crystalloid solutions may result in adverse effects. This includes albumin administration in
the OR and the endovascular/hybrid suite to manage volume depletion resulting from
diuretic use or to prevent or treat vasospasm. (UW Health very low quality evidence;
weak/conditional recommendation)
a. Albumin type: 5%
b. Dose: 12.5 – 25 g (250-500 mLs); repeat as necessary

12. Albumin may be considered for sustaining organ function in brain dead patients while
awaiting organ procurement when crystalloid fluid or pressor administration fails to maintain
mean arterial pressure above 70 mmHg and the plasma albumin is less than 2 g/dL.48 (UW
Health low quality evidence; weak/conditional recommendation)
a. Albumin type: 25%
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b. Dose: 12.5-25 g (50 - 100 mL)

Albumin is harmful and is contraindicated for the following indications:
1. Fluid resuscitation in patients with traumatic brain injury.49 A post-hoc, subgroup analysis of
fluid resuscitation among critically ill patients with traumatic brain injury revealed a higher
mortality rate when albumin was administered as compared to saline. The subgroup was
identified from all critically ill subjects studied in the Saline versus Albumin Fluid Evaluation
Study.18 (UW Health low quality evidence; strong recommendation)
Albumin administration is not recommended for the following indications as available
evidence is insufficient to support use:
1. To correct plasma albumin in patients not described above with plasma albumin > 2.5
g/dL50-52 (UW Health low quality evidence; weak/ conditional recommendation)
2. To treat sepsis without shock16,21 (UW Health moderate quality evidence; weak/ conditional
recommendation)
3. To treat malnutrition, protein losing enteropathies, or malabsorption53,54 (UW Health very
low quality evidence; weak/ conditional recommendation)
4. As fluid resuscitation in patients with acute trauma18,52 (UW Health moderate quality
evidence; weak/ conditional recommendation)
5. Treatment of hepatic encephalopathy in patients with cirrhosis55 (UW Health low quality
evidence; weak/ conditional recommendation)
6. Treatment of hypo-albuminemia without signs of edema or hypotension50-52 (UW Health low
quality evidence; weak/ conditional recommendation)
7. Preoperative hemodilution56 (UW Health low quality evidence; weak/ conditional
recommendation)
8. Fluid expansion in the immediate post-operative period following minor surgery (UW Health
very low quality evidence; weak/ conditional recommendation)
9. Treatment of aneurysmal subarachnoid hemorrhage57 (UW Health low quality evidence;
weak/ conditional recommendation)

Monitoring of albumin administration
Continued need for albumin administration should be assessed daily. Albumin should be
discontinued as soon as therapy is no longer required according to monitored parameters.
(UW Health low quality evidence; strong recommendation)
1. Laboratory
a. Albumin therapy may not be necessary in patients with plasma albumin ≥ 2.5 g/dL
2. Physical assessment: consider discontinuing albumin when goal is reached
a. Blood pressure: SBP > 100 mmHg or MAP > 60 mmHg
b. Urine output: > 0.5 ml/kg/hour
c. Improvement in condition(s) for which albumin was initiated
d. Edema improvement (total body fluid overload and intravascular volume depletion)
e. Other measures of fluid responsiveness

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UW Health Implementation
Potential Benefits:
Implementation of and adherence to the guideline recommendations should result in use of albumin that
is consistent, evidence-based, and cost effective.

Potential Harms:
Patients may experience adverse effects to albumin, even when receiving it for an approved indication
and at a recommended dose.

Pertinent UW Health Policies & Procedures
1. Burn Basics Reference:
https://uconnect.wisc.edu/clinical/references/burn/admission/#General_Admission_Plans
2. Burn Trauma: https://uconnect.wisc.edu/clinical/references/trauma-manual/trauma-care-by-
system/burn-trauma/
3. Nursing Policy #11.10: Percutaneous Paracentesis
4. Nursing Policy #1.01AP: Therapeutic Plasma Exchange

Patient Resources
1. Health Facts For You #5790: Transplant desensitization with plasma exchange and IVIG

Guideline Metrics
1. Periodic medication use evaluation of albumin to assess outcomes, including mortality, adverse
effects, and cost.

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline
recommendations (such as the following) will be reviewed for consistency and modified as
appropriate.

Order Sets
IP – General Care – Adult [692]
Anesthesiology – Adult – Recovery/PACU [1396]
IP – Anesthesiology – ICU – Adult – Postoperative [2952]
IP – Cirrhosis – Adult – Admission [1673]
IP – ECMO – Adult – Post-Cannulation [2459]
IP – Hemodialysis – Adult – Procedure [5138]
DHC – Body – Paracentesis – Adult – Postprocedure [5398]
IP – Body – Paracentesis – Adult – Postprocedure [1607]
IP – Paracentesis – Bedside – Adult – Pre/Postprocedure [2469]
IP – Donor Hepatic Lobectomy – Adult – Postoperative [2884]
IP – Pancreas Transplant – Adult – Postoperative [2889]
IP – Renal/Pancreas Transplant – Adult – Postoperative [2927]
IP – Comprehensive Brain Dead Donor (BDD) Delegation Protocol – Adult – Intensive Care –
Supplemental [4078]
IP – Comprehensive Donation After Cardiac Death (DCD) – Adult – Intensive Care – Supplemental [3627]

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of
patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a
clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit
the clinical condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.






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References

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patients. Cochrane Database Syst Rev. 2013(2):Cd000567.
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cirrhosis: A multidisciplinary perspective. J Hepatol. 2016;64(3):717-735.
4. Caraceni P, Angeli P, Prati D, et al. AISF-SIMTI position paper: the appropriate use of
albumin in patients with liver cirrhosis. Blood Transfus. 2016;14(1):8-22.
5. Liumbruno GM, Bennardello F, Lattanzio A, et al. Recommendations for the use of
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https://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf,
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7. Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in
patients with cirrhosis: revised consensus recommendations of the International Club of
Ascites. Gut. 2015;64(4):531-537.
8. Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment
of hepatorenal syndrome in cirrhosis. Gut. 2007;56(9):1310-1318.
9. Runyon BA, Aasld. Introduction to the revised American Association for the Study of
Liver Diseases Practice Guideline management of adult patients with ascites due to
cirrhosis 2012. Hepatology. 2013;57(4):1651-1653.
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