Clinical perspectives on long-term albumin therapy in decompensated cirrhosis: a nationwide delphi survey in Spain-the ALBA study

Abstract

Background and Aims: Albumin is well established for some acute indications in decompensated cirrhosis, but its long-term use remains controversial. The ALBA study explored expert clinical perspectives, barriers, and current practices regarding long-term albumin therapy in Spain. Methods: A two-round national Delphi study was conducted among 47 hepatology experts from Spanish hospitals with broad geographic coverage. The survey included 40 Delphi statements and 14 items on opinion, attitude, and behaviour across five domains. Consensus was defined as Tastle's coefficient ??0.8. Items with moderate consensus (0.7-0.79) and < 70% agreement, or < 0.7, were re-evaluated in round two. Results: Long-term albumin was reportedly used in 25.5% of centers. However, panellists broadly supported its potential benefit in preventing ascites-related complications and endorsed its use regardless of transplant eligibility. It was prioritised for patients with difficult-to-control ascites (89.3%) and renal impairment (55.2%), though benefits were perceived as lower in late-stage disease. Day hospitals were seen as the most appropriate setting, despite strain. Main barriers included evidentiary limitations, institutional logistics, and pharmacy restrictions. Therapy was viewed as overall safe, with dose-dependent cardiac risk, and considered cost-effective. Strong support was expressed for a national registry to guide implementation. Conclusions: Panellists considered long-term albumin administration to be clinically beneficial and prioritised its use for patients with advanced-stage disease, regardless of transplant candidacy. However, integration into routine practice remains limited due to a lack of robust supporting evidence, along with institutional and logistical barriers. A national registry and targeted strategies to optimise use and resource allocation were endorsed.