Accepted Manuscript Effects of Albumin Treatment on Systemic and Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis Javier Fernández, Joan Clària, Alex Amorós, Ferrán Aguilar, Miriam Castro, Mireia Casulleras, Juan Acevedo, Marta Duran-Güell, Laura Nuñez, Montserrat Costa, Mireia Torres, Raquel Horrillo, Luis Ruiz-del-Árbol, Cándido Villanueva, Verónica Prado, Mireya Arteaga, Jonel Trebicka, Paolo Angeli, Manuela Merli, Carlo Alessandria, Niels Kristian Aagaard, German Soriano, François Durand, Alexander Gerbes, Thierry Gustot, Tania M. Welzel, Francesco Salerno, Rafael Bañares, Victor Vargas, Agustin Albillos, Aníbal Silva, Manuel Morales-Ruiz, Marco Pavesi, Rajiv Jalan, Mauro Bernardi, Richard Moreau, Antonio Páez, Vicente Arroyo PII: S0016-5085(19)33576-0 DOI: https://doi.org/10.1053/j.gastro.2019.03.021 Reference: YGAST 62534 To appear in: Gastroenterology Accepted Date: 14 March 2019 Please cite this article as: Fernández J, Clària J, Amorós A, Aguilar F, Castro M, Casulleras M, Acevedo J, Duran-Güell M, Nuñez L, Costa M, Torres M, Horrillo R, Ruiz-del-Árbol L, Villanueva C, Prado V, Arteaga M, Trebicka J, Angeli P, Merli M, Alessandria C, Aagaard NK, Soriano G, Durand F, Gerbes A, Gustot T, Welzel TM, Salerno F, Bañares R, Vargas V, Albillos A, Silva A, Morales-Ruiz M, Pavesi M, Jalan R, Bernardi M, Moreau R, Páez A, Arroyo V, Effects of Albumin Treatment on Systemic and Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis, Gastroenterology (2019), doi: https://doi.org/10.1053/j.gastro.2019.03.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. brought to you by CORE View metadata, citation and similar papers at core.ac.uk provided by UCL Discovery
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Accepted Manuscript
Effects of Albumin Treatment on Systemic and Portal Hemodynamics and SystemicInflammation in Patients With Decompensated Cirrhosis
Javier Fernández, Joan Clària, Alex Amorós, Ferrán Aguilar, Miriam Castro,Mireia Casulleras, Juan Acevedo, Marta Duran-Güell, Laura Nuñez, MontserratCosta, Mireia Torres, Raquel Horrillo, Luis Ruiz-del-Árbol, Cándido Villanueva,Verónica Prado, Mireya Arteaga, Jonel Trebicka, Paolo Angeli, Manuela Merli,Carlo Alessandria, Niels Kristian Aagaard, German Soriano, François Durand,Alexander Gerbes, Thierry Gustot, Tania M. Welzel, Francesco Salerno, RafaelBañares, Victor Vargas, Agustin Albillos, Aníbal Silva, Manuel Morales-Ruiz, MarcoPavesi, Rajiv Jalan, Mauro Bernardi, Richard Moreau, Antonio Páez, VicenteArroyo
To appear in: GastroenterologyAccepted Date: 14 March 2019
Please cite this article as: Fernández J, Clària J, Amorós A, Aguilar F, Castro M, Casulleras M, AcevedoJ, Duran-Güell M, Nuñez L, Costa M, Torres M, Horrillo R, Ruiz-del-Árbol L, Villanueva C, Prado V,Arteaga M, Trebicka J, Angeli P, Merli M, Alessandria C, Aagaard NK, Soriano G, Durand F, GerbesA, Gustot T, Welzel TM, Salerno F, Bañares R, Vargas V, Albillos A, Silva A, Morales-Ruiz M, PavesiM, Jalan R, Bernardi M, Moreau R, Páez A, Arroyo V, Effects of Albumin Treatment on Systemicand Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis,Gastroenterology (2019), doi: https://doi.org/10.1053/j.gastro.2019.03.021.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.
brought to you by COREView metadata, citation and similar papers at core.ac.uk
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ACCEPTED MANUSCRIPT10. O'Brien AJ, Fullerton JN, Massey KA, et al. Immunosuppression in acutely decompensated
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Author names in bold designate shared co-first authorship.
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Figure legends
Figure 1
Changes in serum albumin concentration and plasma renin activity (PRA) induced by treatment
with high albumin dosage (HAlbD, blue color in all panels) and low albumin dosage (LAlbD, red
color) in the 18 patients included in the Pilot-PRECIOSA Study. Panel A: Individual changes in
serum albumin concentration among the 13 patients with baseline hypoalbuminemia (serum
albumin concentration <34 g/L). The horizontal lines indicate the upper and lower normal limits of
serum albumin. All the six patients with hypoalbuminemia treated with HAlbD developed a rapid
increase (within 2 weeks) in serum albumin concentration up to normal levels, remaining so
during the remaining 10 study-weeks. In contrast, although all the 7 patients with baseline
hypoalbuminemia treated with LAlbD increased the serum levels of albumin during treatment,
only one normalized the serum albumin concentration. Panels B to D: Two factors influenced the
response to albumin treatment. The first factor was the albumin dosage: Among the 13 patients
with baseline hypoalbuminemia, the individual absolute median increase in serum albumin was
almost double in patients receiving HAlbD than in those receiving LAlbD (Panel B); The second
factor was the feedback mechanism by which baseline serum albumin concentration influences
the hepatic synthesis of albumin. In most patients without hypoalbuminemia (Panel C), the
inhibition of hepatic synthesis of albumin prevented the increase in the serum concentration of
albumin to abnormal levels during albumin treatment. This feedback mechanism was also
reflected by the close inverse correlation between the baseline serum albumin concentration and
the mean increase in serum albumin during treatment (Panel D). The lower the baseline levels of
serum albumin, the higher the absolute mean increase in the serum concentration of albumin in
both the LAlbD and HAlbD groups. Panel E. Circulatory dysfunction was extremely instable
during albumin treatment in patients receiving LAlbD, with high peaks of PRA in six patients.
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one patients presenting one peak of PRA throughout treatment.
Figure 2
Changes in IL-6 and other cytokines induced by treatment with high albumin dosage (HAlbD, blue
color in all panels) and low albumin dosage (LAlbD, red color) in the 15 patients included in the
Pilot-PRECIOSA study with sequential cytokines measurements. Panel A. The degree of
systemic inflammation, as estimated by repeated measurements of plasma IL-6 in baseline
conditions and during treatment was extremely unstable in 4 patients receiving LAlbD and in one
receiving HAlbD; Panel B. In the remaining patients there was a marked suppression of the
circulating plasma levels of IL-6 (mainly in patients receiving HAlbD) or no-to-minor changes
(mainly in patients receiving LAlbD); Panels C and D. Data derived from the assessment of a
large panel of inflammatory cytokines at baseline and at week 6 showed that plasma levels of IL-
6, VEGF, G-CSF and IL-1ra had a median reduction from baseline (IQR; %) which was
significantly greater among patients treated with HAlbD than among those receiving LAlbD.
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HAlbD group (n=8) LAlbD group (n=10) P value # Median (IQR)
Serum Albumin Concentration Baseline (g/L) 27.6 (22.7 to 34.0) 26.5 (24.8 to 40.3) 0.83 “On treatment” Average Value (g/L) 39.2 (38.7 to 43.0)** 33.3 (31.8 to 37.9)*** 0.004 Absolute Change (g/L) 12.7 (8.5 to 16.6)** 5.7 (-1.8 to 8.0)*** 0.01 Percentage Change (%) 48.7 (26.7 to 71.3)** 20.2 (-4.1 to 32.5)*** 0.04 Plasma Renin Activity Baseline (ng/mL.h) 5.5 (3.6 to 7.9) 7.9 (3.8 to 12.3) 0.41 “On treatment” Average Value (ng/mL.h) 4.9 (3.9 to 5.8) 6.9 (3.8 to 11.3) 0.17 Absolute Change (ng/mL) 0.2 (-4.2 to 1.3) -0.4 (-5.5 to 5.8) 0.64 Percentage Change (%) 2.0 (-44.4 to 36.2) -6.7 (-45.3 to 146.2) 0.69 Plasma IL-6 Concentration Baseline (pg/mL) 123.5 (51.5 to 151.5) 41.5 (25.8 to 75.0) 0.02 “On treatment” Average Value (pg/mL) 62.5 (24.5 to 93.6)** 57.5 (30.0 to 79.2) 0.76 Absolute Change (pgm/L) -53.0 (-108.0 to -18.0)** -3.2 (-11.1 to 30.0) 0.04 Percentage Change (%) -56.0 (-68.8 to -24.2)** -7.6 (-15.7 to 79.7) 0.04
* For each variable in each patient, the average value during treatment was obtained by using all the values of this variable, available “on-treatment”. IQR denotes interquartile range, Cells colored in green show P values of less than 0.05. **P <0.05 for the within-group comparison with baseline values. ***P=0.05 for the within-group comparison with baseline values. # P value for the between-group comparison.
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Table 2. Baseline Plasma Levels Of Cytokines Among Healthy Subjects (HS), Patients From The Pilot-PRECIOSA (P-PR) Study, And Patients From The INFECIR-2 (INF-2) Study.*
Cytokine
HS (N=25)
P-PR Study (N=15)
INF-2 Study (N=78)
P value
HS vs p-PR HS vs INF-2 p-PR vs INF-2
TNFαααα
Median level (IQR) — pg/mL 12.3 (11.5 to 16.9) 21.8 (16.0 to 30.6) 32.0 (21.9 to 49.8) 0.001 0.0001 0.04 Missing variable — no. (%) 0 (0) 0 (0) 0 (0) G-CSF
Median level (IQR) — pg/mL 3.6 (2.4 to 5.7) 20.0 (8.8 to 156.9) 74.4 (32.0 to 155.5) 0.0008 0.0001 0.11
Missing variable — no. (%) 0 (0) 1 (7) 17 (22)
IL-1ra Median level (IQR) — pg/mL 7.1 (3.8 to 13.2) 13.1 (9.1 to 32.8) 29.6 (8.3 to 76.5) 0.02 0.0001 0.26 Missing variable — no. (%) 0 (0) 0 (0) 0 (0) IL-6 Median level (IQR) — pg/mL 0.9 (0.9 to 0.9) 10.5 (8.0 to 25.1) 37.1(22.6 to 107.6) 0.0001 0.0001 0.0001 Missing variable — no. (%) 0 (0) 0 (0) 0 (0) IL-10 Median level (IQR) — pg/mL 1.1 (1.1 to 2.4) 2.7 (0.8 to 10.8) 10.9 (6.7 to 19.0) 0.20 0.0001 0.02 Missing variable — no. (%) 0 (0) 3 (20) 13 (17) IL-17A Median level (IQR) — pg/mL 0.7 (0.7 to 3.3) 17.7 (2.3 to 32.4) 3.2 (1.4 to 7.2) 0.0002 0.002 0.05 Missing variable — no. (%) 0 (0) 3 (20) 0 (0) IFNγγγγ
Median level (IQR) — pg/mL 3.0 (2.2 to 4.7) 6.7 (2.1 to 35.8) 6.8 (1.5 to 18.4) 0.11 0.04 0.49 Missing variable — no. (%) 0 (0) 0 (0) 0 (0) VEGF
Median level (IQR) — pg/mL 24.4 (14.7 to 45.2) 59.0 (26.3 to 230.7) 61.0 (32.1 to 183.0) 0.02 0.002 0.77
Missing variable — no. (%) 0 (0) 1 (7) 32 (41)
* Cells colored in green show P values of less than 0.05. The cell colored in yellow shows a P value of 0.05. IQR denotes interquartile range, TNF tumor necrosis factor, G-CSF granulocyte colony-stimulating factor, IL interleukin, IL-1ra interleukin-1 receptor antagonist, IFN interferon, and VEGF vascular endothelial growth factor.
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Table 3. Plasma Levels Of Cytokines At Baseline And At The 6th Week Of Treatment In Patients Receiving Either Low Albumin Dosage (LAlbD) Or High Albumin Dosage (HAlbD) in The Pilot PRECIOSA Study.*
Cytokine LAlbD Group (N=10)
HAlbD Group (N=5)
P Value for Between-Group Comparison
Undetectable
Levels
Baseline
Cytokine Level
Absolute Change from Baseline
Percentage Change
from Baseline
Undetectable
Levels
Baseline
Cytokine Level
Absolute Change from Baseline
Percentage Change
from Baseline
Absolute Change from
Baseline
Percentage Change from
Baseline
no. (%) Median (IQR) — pg/mL
Median (IQR) — pg/mL
Median (IQR) — %
no. (%)
Median (IQR) — pg/mL
Median (IQR) — %
Median (IQR) — %
TNFαααα 0 (0) 20.3 (13.6 to 28.1) 1.8 (-0.7 to 3.5) 11.0 (-3.5 to 15.9) 0 (0) 30.9 (18.4 to 53.6) -4.9 (-9.3 to 0.7) -15.1 (-16.1 to 7.5) 0.12 0.19
G-CSF 0 (0) 20.0 (8.8 to 156.9) 4.9 (-1.4 to 13.8) 20.5 (-14.5 to 60.3) 1 (20) 47.3 (6.1 to 315.5) -63.1 (-79.5 to -53.2) -63.1 (-79.5 to -53.2) 0.05 0.03
IL-1ra 0 (0) 13.1 (10.2 to 35.3) 2.8 (-1.2 to 18.9) 28.8 (-15.2 to 53.6) 0 (0) 8.5 (6.7 to 29.3) -4.0 (-7.0 to -2.8) -70.3 (-82.9 to -13.8) 0.03 0.04
IL-6 0 (0) 8.9 (6.5 to 24.6) 0.8 (-2.5 to 7.4) 44.1 (-11.7 to 83.9) 0 (0) 10.7 (10.5 to 28.4) -9.2 (-14.2 to -5.0) -50.1 (-67.3 to -46.8) 0.01 0.01
IL-10 2 (20) 1.8 (0.6 to 10.8) 0.3 (-0.7 to 1.3) -3.1 (-42.8 to 27.0) 1 (20) 5.6 (2.2 to 27.6) -3.4 (-14.9 to 0.7) -24.4 (-66.2 to 21.3) 0.35 0.43
IL-17A 3 (30) 24.7 (1.4 to 33.7) 0.65 (-0.9 to 9.8) 12.4 (-46.1 to 40.8) 0 (0) 15.4 (2.9 to 19.9) -9.2 (-16.4 to -1.5) -59.6 (-82.4 to -51.7) 0.07 0.14
IFNγγγγ 0 (0) 5.6 (2.6 to 49.0) 0.2 (-0.6 to 2.2) 5.6 (-7.7 to 32.0) 0 (0) 8.7 (1.7 to 22.6) -4.5 (-14.8 to -0.2) -51.7 (-65.6 to -15.2) 0.12 0.12
VEGF 1 (10) 198.0 (56.1 to 230.7) 26.5 (0.0 to 50.8) 11.7 (0.0 to 29.2) 0 (0) 26.3 (23.5 to 50.1) -8.4 (-17.6 to -4.0) -75.2 (-91.4 to -16.8) 0.03 0.01
* Cells colored in green show P values of less than 0.05. Cells colored in yellow show a P value of 0.05. IQR denotes interquartile range, TNF tumor necrosis factor, G-CSF granulocyte colony-stimulating factor, IL interleukin, IL-1ra interleukin-1 receptor antagonist, IFN interferon, and VEGF vascular endothelial growth factor.
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Cells colored in green show P values of less than 0.05. RAP denotes: right atrial pressure; MPAP: mean pulmonary artery pressure; PCWP: pulmonary capillary wedge pressure; LV: left ventricular; SVRI: systemic vascular resistance index; MAP: mean arterial pressure; ANP: atrial natriuretic peptide; BNP: brain natriuretic peptide; FHVP: free hepatic venous pressure; WHVP: wedge hepatic venous pressure; HVPG: hepatic venous pressure gradient; AST: aspartate aminotransferase; ALT: alanine aminotransferase; BUN: blood urea nitrogen; MELD: model for end stage liver disease. Normal values are: right atrial pressure: 2-10 mmHg; mean pulmonary arterial pressure: 10-25 mmHg; pulmonary capillary pressure: 6-14 mmHg; cardiac index: 2.5-4 L/min/m2; SV: 60-100 ml; LV stroke work index: 45-75 g.m/m2/beat; SVRI: 1970-2390 dyn.sec/cm5/m2; MAP: 80-95 mm Hg; Ejection fraction >50%; ANP: 9-24 fmol/mL; BNP: 4-37 pg/mL; HVPG: 1-5 mm Hg; hepatic blood flow: 1200-1500 ml/min
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Table 5. Baseline Plasma Levels of Cytokines, And Their Changes During The First Week Of Treatment, In Patients From The INFECIR-2 Study Who Were Randomized To Receive Either Antibiotics Alone Or Albumin plus Antibiootics.*
Cytokine Antibiotics Alone (N=40) Albumin Plus Antibiotics (N=38) P Value for Change From Baseline
Undetectable
Levels
Baseline Level
Absolute change
From Baseline
Percentage Change From Baseline
P Value for Change From Baseline
Undetectable
Levels
Baseline Level
Absolute change from Baseline
Percentage Change from Baseline
no. (%)
Median (IQR) — pg/mL
Median (IQR) — pg/mL
Median (IQR) — %
Absolute
change
Percentage change
no. (%)
Median (IQR) — pg/mL
Median (IQR) — %
Median (IQR) — %
Absolute change
Percentage change
TNFαααα 0 (0) 37.9 (23.3 to 50.0)
-2.8 (-12.6 to 3.2)
-8.2 (-28.9 to 11.9)
0.05 0.01 0 (0) 31.1 (21.2 to 45.3)
-3.4 (-14.7 to 3.1)
-16.2 (-40.5 to 12.8)
0.01 0.04
G-CSF 9 (23) 74.4 (19.2 to 185.5)
-3.4 (-55.3 to 11.5)
-21.2 (-91.4 to 21.5)
0.33 0.85 8 (21) 73.5 (33.6 to 115.0)
-41.5 (-65.1 to 8.4)
-58.6 (-88.8 to 30.2)
0.01 0.01
IL-1ra 0 (0) 29.6 (8.3 to 71.5)
-0.6 (-28.0 to 9.0)
-5.9 (-51.5 to 23.6)
0.37 0.31 0 29.9 (8.3 to 76.5)
-0.5 (-34 to 2.1)
-3.5 (-73.0 to 8.3)
0.05 0.28
IL-6 0 (0) 37.7 (18.3 to 94.7)
-7.0 (-19.9 to 20.7)
-14.8 (-43.5 to 66.4)
0.53 0.27 0 (0) 36.9 (23.9 to 158.9)
-7.7 (-33.1 to 0.3)
-23.0 (-55.0 to 3.8)
0.003 0.005
IL-10 8 (20) 10.7 (6.3 to 20.9)
-0.2 (-6.7 to 4.4)
-1.8 (-56.7 to 50.1)
0.74 1.00 5 (13) 11.0 (6.7 to 15.1)
-1.5 (-7.6 to 2.8)
-15.6 (-53.5 to 63.0)
0.03 0.03
IL-17A 0 (0) 3.7 (1.2 to 8.2)
0.1 (-1.7 to 1.3)
2.5 (-38.6 to 81.1)
0.92 1.00 0 (0) 2.7 (1.6 to 7.2)
-0.5 (-2.7 to 0.4)
-15.4 (-52.4 to 29.9)
0.05 0.09
IFNγγγγ 0 (0) 4.8 (1.2 to 15.6)
-0.2 (-6.2 to 1.3)
-7.9 (-51.7 to 37.1)
0.17 0.52 0 (0) 8.4 (2.0 to 19.7)
-0.5 (-8.6 to 4.3)
-24.8 (-63.3 to 52.9)
0.48 0.24
VEGF 16 (40) 65.4 (45.6 to 204.0)
-18.5 (-41.4 to 18.2)
-16.4 (-45.3 to 29.4)
0.30 0.31 16 (42) 50.6 (24.1 to 183.0)
-13.9 (-49.0 to 11.9)
-24.7 (-36.9 to 32.5)
0.10 0.29
* Changes during the first week of albumin treatment were assessed between day 3 and day 7 after inclusion. There were no significant between-group differences in cytokine levels at baseline. Cells colored in green show P values of less than 0.05. Cells colored in yellow show a P value of 0.05. IQR denotes interquartile range, TNF tumor necrosis factor, G-CSF granulocyte colony-stimulating factor, IL interleukin, IL-1ra interleukin-1 receptor antagonist, IFN interferon, and VEGF vascular endothelial growth factor.
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ACCEPTED MANUSCRIPTSUPPLEMENTARY APPENDIX
This appendix has been provided by the authors to give readers additional information about their
work.
Supplement to: Fernández J, Clària J, Amorós A, et al. Albumin Treatment in Decompensated
Cirrhosis: Effects On Systemic And Portal Hemodynamics And On Systemic Inflammation
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ACCEPTED MANUSCRIPTSupplementary Appendix
Table of contents
Pages
List of investigators
Supplementary Text Methods 2
Supplementary Table 1 Supplementary Table 1. Baseline Characteristics And Outcomes Of Patients Included In The Pilot PRECIOSA Study.
1
Supplementary Table 2 Lower Limit Of Detection, Expressed As The Minimun Detectable Concentration, For Each Analyte Measured In The Study.
1
Supplementary Table 3 Plasma Levels of Chemokines, Growth Factors, Markers Of Macrophage Activation, And Markers of Endothelial Dysfunction And Of Coagulation/Platelet Function, At Baseline And The 6th Week Of Treatment in Patients Receiving Either Low Albumin Dosage (LalbD) or High Albumin Dosage (HAlbD), in the Context of the Pilot PRECIOSA Study.
2
Supplementary Table 4 Baseline Plasma Levels of Chemokines, Growth Factors, Markers Of Macrophage Activation, And Markers of Endothelial Dysfunction And Of Coagulation/Platelet Function, and Their Changes During the First Week of Treatment, In Patients From The INFECIR-2 Study Who Were Randomized To Receive Either Standard Medical Therapy Alone Or SMT Plus Albumin.
2
References
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Supplementary Methods
Inclusion and Exclusion Criteria In The Pilot PRECIOSA Study
Inclusion criteria: age between 18 and 80 years, presence of ascites, renal dysfunction [serum
pneumonia or bacteremia required the presence of 1 or more of these criteria for inclusion, 2 or
more were required in the rest]. Additionally, patients with urinary or suspected infections required
the presence of at least 1 diagnostic criterion of systemic inflammatory response syndrome
(SIRS) and serum CRP levels ≥1 mg/dl to be included.
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ACCEPTED MANUSCRIPTExclusion criteria: > 72h after infection diagnosis; acute or sub-acute liver failure; septic shock;
endocarditis; fungal infection; severe acute respiratory distress syndrome (PaO2/Fi02 ≤100),
active or recent variceal bleeding (unless controlled for > 48h); type-1 HRS (IAC criteria); ACLF
grade-3 (3 or more organ failures defined according to the Canonic Study criteria); renal
replacement therapy; malignancy (except for hepatocellular carcinoma within Milan criteria or
non-melanocytic skin cancer); moderate or severe chronic heart failure (NYHA class II, III or IV);
severe chronic pulmonary disease (GOLD IV); previous liver transplantation; severe psychiatric
disorders that prevent the patient from giving informed consent and from making autonomous
decisions; HIV infection (except for patients under antiretroviral therapy with undetectable viral
load, CD4 levels > 200/mm3 and no previous history of opportunistic infections diagnostic of
AIDS); contraindications to albumin (allergy, signs of pulmonary edema); albumin administration
(≥ 80 g) in the last 2 days; spontaneous bacterial peritonitis co-infection; administration of any
investigational drug within 90 days prior to randomization; pre-menopausal women not practicing
an acceptable method of birth control; refusal to participate; patients who could not provide prior
informed consent and when there was documented evidence that the patient had no legal
surrogate decision maker and it appeared unlikely that the patient would regain consciousness or
sufficient ability to provide delayed informed consent; physician and team not committed to
intensive care if needed.
Laboratory methods
PRA was measured using radioimmunoassay (GammaCoat Plasma Renin Activity, DiaSorin,
Saluggia, Italy, normal values: 0.3-2.5 ng/mL.h); PRC was measured using a chemiluminescent
immunoassay Liaison Direct Renin on the LIAISON Analyzer (DiaSorin) (normal values 2.8-39.9
microUI/ml); ANP was measured by radioimmunoassay (Euro-Diagnostica, Arnhem, The
Netherlands); BNP was determined by chemiluminiscence immunoassay run in an Advia Centaur
XP (Siemens Health Care, Tarrytown, NY) (normal values: 9-24 f mol/l and 4-37 pmol/ml). The
plasma concentration of IL-6 was measured by ELISA (Diasource, Louvain-la-Neuve, Belgium)
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ACCEPTED MANUSCRIPT(normal values <5 pg/mL). Serum albumin measurement was performed using standard routine
methods. Plasma levels of a panel of 24 inflammatory cytokines, 10 chemokines, 4 growth
factors, 2 markers of endothelial dysfunction and 2 markers of coagulation/platelet function were
performed using two multiplex immunoassays based on Luminex multi-analyte profiling
technology (Human Cytokine/Chemokine Magnetic bead panel Premixed 38 Plex Kit and Human
Sepsis Magnetic bead panel 1, Merk Millipore, Billerica, MA). Among the 24 cytokines measured,
11 were not detectable in any patient/healthy subject and were not included in this analysis.
Signals were read in a Luminex 100 Bioanalyzer (Luminex Corp., Austin, TX). A five-parameter
logistic regression model was used to create standard curves and to calculate the concentration
of each sample with the standard version of the Milliplex Analyst software (Merck Millipore). The
lower limit of detection of each analyte is indicated in supplementary table 2. Normal values given
in table 2 were obtained from 24 healthy volunteers aged 18-65 years. The plasma levels of 2
soluble markers of macrophage activation (sCD163 and sMR/sCD206) were determined by
enzyme-linked immunosorbent assays (Antibodies on line, Aachen, Germany).
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ACCEPTED MANUSCRIPTSupplementary Table 1. Baseline Characteristics And Outcomes Of Patients Included In The Pilot PRECIOSA Study.*
Patients (N=18)
Baseline data
Age (years) 56 (50-64)
Male sex, n (%) 13 (72)
Alcoholic cirrhosis, n (%) 12 (67)
Previous variceal bleeding, n (%) 5 (28)
ß-blockers, n (%) 7 (39)
Previous SBP, n (%) 5 (28)
Long-term norfloxacin prophylaxis, n (%) 8 (44)
Previous hepatic encephalopathy, n (%) 7 (39)
Diabetes mellitus, n (%) 3 (17)
HCC, n (%) 1 (6)
Mild hepatic encephalopathy, n (%) 2 (11)
Ascites, n (%) 18 (100)
Blood leukocyte count, x109/L 4.2 (3.3-7.3)
Hematocrit, % 30 (27-34)
Platelet count, x109/L 88 (60-169)
Serum bilirubin, mg/dL 2.0 (1.4-4.0)
Serum albumin, g/L 27 (25-36)
INR 1.4 (1.2-1.8)
Serum creatinine, mg/dL 1.2 (0.8-1.4)
BUN, mg/dL 23 (15-35)
Serum sodium, mEq/L 132 (128-135)
Serum C-reactive protein, mg/dL 0.7 (0.3-1.1)
Child-Pugh score, points 9 (7-10)
MELD score, points 16 (13-17)
Main complications during 3-month follow-up
Variceal bleeding, n (%) 2 (11)
Other gastrointestinal bleeding, n (%) 2 (11)
Non-SBP infections, n (%) 4 (22)
*The pilot PRECIOSA study was an open-label, multicenter, nonrandomized (single-group), prospective, phase 4 investigation of albumin treatment in patients with decompensated cirrhosis without bacterial infection. Continuous variables are expressed as median (interquartile range). SBP
denotes spontaneous bacterial peritonitis, HCC hepatocellular carcinoma, INR international normalized ratio, BUN blood urea nitrogen, and MELD Model for End-Stage Liver Disease.
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ACCEPTED MANUSCRIPTSupplementary Table 2. Lower Limit Of Detection, Expressed As The Minimun Detectable Concentration,
For Each Analyte Measured In The Study*
*Minimum Detectable Concentration was calculated using MILLIPLEX Analyst 5.1. It measures the true limits of
detection for an assay by mathematically determining what the empirical Minimum Detectable Concentration would
be if an infinite number of standard concentrations were run for the assay under the same conditions.
Analyte Minimum Detectable Concentration
EGF (pg/ml) 2.8
FGF-2 (pg/ml) 7.6
Eotaxin (pg/ml) 4.0
TGF-α (pg/ml) 0.8
G-CSF (pg/ml) 1.8
Flt-3L (pg/ml) 5.4
GM-CSF (pg/ml) 7.5
Fractalkine (pg/ml) 22.7
IFNα2 (pg/ml) 2.9
IFNγ (pg/ml) 0.8
GROα (pg/ml) 9.9
IL-10 (pg/ml) 1.1
MCP-3 (pg/ml) 3.8
IL-12P40 (pg/ml) 7.4
MDC (pg/ml) 3.6
IL-12P70 (pg/ml) 0.6
IL-13 (pg/ml) 1.3
IL-15 (pg/ml) 1.2
sCD40L (pg/ml) 5.1
IL-17 (pg/ml) 0.7
IL-1RA (pg/ml) 8.3
IL-1α (pg/ml) 9.4
IL-9 (pg/ml) 1.2
IL-1β (pg/ml) 0.8
IL-2 (pg/ml) 1.0
IL-3 (pg/ml) 0.7
IL-4 (pg/ml) 4.5
IL-5 (pg/ml) 0.5
IL-6 (pg/ml) 0.9
IL-7 (pg/ml) 1.4
IL-8 (pg/ml) 0.4
IP-10 (pg/ml) 8.6
MCP-1 (pg/ml) 1.9
MIP-1α (pg/ml) 2.9
MIP-1β (pg/ml) 3.0
TNFα (pg/ml) 0.7
TNFβ (pg/ml) 1.5
VEGF (pg/ml) 26.3
sICAM-1 (pg/ml) 17.7
sVCAM-1 (pg/ml) 10.7
tPAI-1 (pg/ml) 3.2
MIF (pg/ml) 2.7
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Supplementary Table 3. Plasma Levels of Chemokines, Growth Factors, Markers Of Macrophage Activation, And Markers of Endothelial Dysfunction And Of Coagulation/Platelet Function, At Baseline And The 6th Week Of Treatment in Patients Receiving Either Low Albumin Dosage (LAlbD) or High Albumin Dosage (HAlbD) in the Pilot PRECIOSA Study.*
Variable
LAlbD group (N=10)
HAlbD Group (N=5)
P Value for Between-Group Comparison
Undetectable
Levels
Baseline
Cytokine Level
Absolute Change
From Baseline
Percentage Change from Baseline
Undetectable
Levels
Baseline
Cytokine Level
Absolute Change from
Baseline
Percentage Change From
Baseline
Absolute Change
from Baseline
Percentage Change from
Baseline
no. (%) Median (IQR) — pg/mL
Median (IQR) — pg/mL
Median (IQR) — %
no. (%) Median (IQR) — pg/mL
Median (IQR) — pg/mL
Median (IQR) — %
Chemokines
GROα/CXCL1 0 (0) 675.0 (256.0 to 916.2)
76.2 (-100.0 to 120.5)
19.1 (-19.0 to 58.4)
1 (20) 509.9 (287.9 to 1,717.1)
-157.6 (-1,230.1 to -65.5)
-31.3 (-57.1 to -10.5)
0.10 0.08
MCP-1/CCL2 0 (0) 307.1 (244.1 to 375.0)
-2.9 (-33.4 to 141.3)
-1.6 (-9.0 to 57.6)
0 (0) 292.8 (263.1 to 341.6)
107.4 (53.0 to 107.9)
20.8 (18.1 to 31.4)
0.66 0.76
MIP-1α/CCL3 4 (40) 7.0 (6.8 to 10.8)
-4.3 (-7.0 to 3.6)
-57.4 (-100.0 to 12.7)
1 (20) 6.6 (4.0 to 23.5)
-2.1 (-7.4 to -1.1)
-29.4 (-37.7 to -13.1)
0.75 0.59
MIP-1β/CCL4 0 (0) 41.7 (15.2 to 65.2)
2.8 (-9.8 to 5.4)
13.6 (-9.7 to 34.6)
0 (0) 35.3 (30.5 to 41.4)
-11.8 (-20.4 to -9.6)
-45.6 (-48.8 to -33.3)
0.07 0.02
MCP-3/CCL7 2 (20) 7.2 (3.8 to 14.7)
0.6 (-1.9 to 4.2)
15.7 (-17.7 to 42.3)
1 (20) 14.1 (4.5 to 23.3)
-3.7 (-12.9 to 0.0)
-26.2 (-55.2 to 5.1)
0.13 0.23
IL-8/CXCL8 0 (0) 48.8 (34.0 to 78.6)
-7.4 (-11.1 to 4.3)
-15.0 (-26.1 to 15.9)
0 (0) 75.1 (50.8 to 106.2)
-32.1 (-47.9 to -13.8)
-37.3 (-42.8 to -27.2)
0.08 0.10
IP-10/CXCL10 0 (0) 352.1 (187.2 to 509.9)
29.3 (-24.9 to 283.6)
15.6 (-9.7 to 85.9)
0 (0) 623.9 (187.8 to 830.5)
52.7 (-218.2 to 66.8)
35.6 (-35.0 to 40.3)
0.76 0.43
Eotaxin/CXCL11 0 (0) 126.8 (75.3 to 151.6)
11.1 (-12.4 to 31.4)
7.4 (-9.2 to 24.9)
0 (0) 128.7 (111.5 to 134.0)
-5.9 (-29.4 to -0.7)
-2.9 (-26.3 to -0.5)
0.29 0.36
Fractalkine/CX3CL1 2 (20) 45.3 (21.1 to 430.2)
-11.7 (-228.1 to 1.7)
-27.0 (-64.0 to 5.8)
1 (20) 22.7 (14.4 to 31.5)
-6.1 (-6.8 to -2.8)
-23.3 (-59.3 to -8.6)
0.49 0.73
MDC/CCL22 0 (0) 733.9 (547.0 to 1,289.0)
72.8 (-119.7 to 105.9)
6.6 (-26.2 to 17.8)
0 (0) 573.2 (529.9 to 809.5)
164.8 (36.9 to 193.8)
22.5 (8.4 to 28.8) 0.24 0.16
Growth Factors
EGF 2 (20) 37.3 (12.9 to 63.3)
-3.7 (-15.3 to 11.0)
-10.9 (-38.4 to 134.1)
2 (40) 5.2 (5.2 to 45.4)
4.8 (-2.4 to 6.9)
15.3 (-46.4 to 92.5)
0.76 1.00
MIF 1 (10) 59.8 (53.9 to 63.7)
-1.0 (-48.7 to 14.3)
-3.2 (-32.8 to 31.2)
1 (20) 91.2 (55.8 to 207.2)
74.4 (25.1 to 5,394.3)
103.21 (5.51 to 8,366.60)
0.11 0.19
FGF2 1 (10) 58.9 (36.5 to 85.9)
3.5 (-3.2 to 14.8)
2.8 (-5.5 to 33.5)
0 (0) 70.7 (22.0 to 82.4)
-31.8 (-44.4 to 0.0)
-27.57 (-62.86 to 0.00)
0.27 0.20
Markers of coagulation/platelet function
PAI-1 1 (10) 18862 (16401 to 19473)
513.0 (-2,709.0 to 2,706.0)
2.72 (-10.7 to 16.5)
1 (20) 9357 (8422.5 to 12299.5)
-2887.0 (-3,247.0 to 210.5)
-25.18 (-32.65 to 6.10)
0.39 0.14
sCD40L 0 (0) 612.8 (285.3 to 1497.0)
-184.8 (-471.7 to 0.0)
-18.15 (-52.8 to 0.0)
0 (0) 211.69 (43.8 to 635.2)
64.2 (-477.7 to 196.9)
146.58 (-34.18 to 447.03)
0.67 0.24
Supplementary Table 3. (Continued.)
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Markers of macrophage and lymphocyte activation
ng/mL ng/mL
sCD163 (ng/ml) (9/4) 1 (10) 464.7 (86.1 to 631.0)
13.1 (-26.6 to 49.1)
6.8 (-46.6 to 24.6)
1 (20) 616.9 (488.0 to 692.6)
-31.0 (-131.6 to 156.6)
-5.25 (-20.98 to 24.00)
0.70 0.94
sMR/sCD206 (ng/ml) (9/4)
1 (10) 152.5 (120.7 to 287.5)
19.0 (-7.8 to 57.9)
9.7 (-2.7 to 48.0)
1 (20) 237.4 (183.9 to 309.6)
37.2 (-33.3 to 69.4)
14.04 (-8.63 to 31.72)
0.94 0.82
Markers of endothelial dysfunction
µg/mL µg/mL
sICAM-1 1 (10) 0.06 (0.04 to 0.08)
-0.0003 (-0.005 to 0.01)
-0.48 (-9.12 to 4.72)
1 (20) 0.13 (0.09 to 0.25)
-0.004 (-0.06 to -0.0003)
-3.29 (-17.44 to 0.14)
0.39 0.32
sVCAM-1 1 (10) 0.28 (0.20 to 0.31)
-0.005 (-0.06 to 0.05)
-1.54 (-14.01 to 27.08)
1 (20) 0.36 (0.25 to 0.43)
-0.05 (-0.11 to -0.03)
-20.66 (-30.10 to -12.44)
0.14 0.19
*The pilot PRECIOSA study enrolled patients with decompensated cirrhosis unrelated to bacterial infection. The LAlbD group received 1 g/kg b.w. of albumin every two weeks
and the HAlbD group received 1.5 g/kg b.w. of albumin every week. Levels of molecules were measured using Luminex and enzyme immunoassays. The usual symbol of
molecules was given together with its alias for most of them (usual symbol/alias). P values were calculated with the use of nonparametric tests. The cell colored in green shows
P values of less than 0.05. IQR denotes interquartile range, GROα growth-regulated alpha protein, CXCL C-X-C motif chemokine ligand, MCP monocyte chemotactic
Supplementary Table 4. Baseline Plasma Levels of Chemokines, Growth Factors, Markers Of Macrophage Activation, And Markers of Endothelial Dysfunction And
Of Coagulation/Platelet Function, and Their Changes During the First Week of Treatment, In Patients From The INFECIR-2 Study Who Were Randomized To Receive
Either Antibiotics Alone Or Albumin-Plus-Antibiotics.*
* The INFECIR-2 study enrolled patients with decompensated cirrhosis and infection unrelated to spontaneous bacterial peritonitis. Levels of molecules were measured using
Luminex and enzyme immunoassays. The usual symbol of molecules was given together with its alias for most of them (usual symbol/alias). Changes during the first week of
albumin treatment were assessed between day 3 and day 7 after inclusion. There were no significant between�group differences in cytokine levels at baseline. P values for
within-group comparisons were calculated with the use of nonparametric tests. Cells colored in green show P values of less than 0.05. IQR denotes interquartile range, GRO-α