From Adults to Children: Rethinking Albumin Therapy in Pediatric Cirrhosis

Albumin is a multifunctional protein with pivotal physiological roles, including maintenance of oncotic pressure, ligand binding and transport, antioxidant activity, immunomodulation, antithrombotic effects, and detoxification. Liver disease leads to quantitative as well as qualitative reduction in albumin concentrations. Oxidized albumin increases with cirrhosis severity, reducing its function and effective concentration. Recently, some studies have shown the presence of abnormal albumin isoforms in cirrhotic children. Reversibly oxidized human non-mercaptalbumin-1 (HNA1) and irreversibly oxidized human non-mercaptalbumin-2 (HNA2) have been shown to predict morbidity and mortality. Albumin dysfunction in addition to hypoalbuminemia introduces the concept of effective albumin concentration, a potential predictor of poor outcomes in pediatric cirrhosis. Long-term albumin infusion in adults with cirrhosis remains controversial as evidenced by large randomized controlled trials. As in adults, the therapeutic indications for albumin therapy in children with cirrhosis are complex and not straightforward. This review article analyses the basic albumin structure, versatile physiological functions of albumin, the implications of its abnormal forms in liver disease, and its therapeutic potential and challenges in albumin infusion therapy. The large number of ongoing studies and clinical trials for optimal use of albumin underscores its paramount position in the management of complications related to liver disorders and in improving patient outcomes.