1. Lancet. 2018 Jun 16;391(10138):2417-2429. doi: 10.1016/S0140-6736(18)30840-7.
Epub 2018 Jun 1.

Long-term albumin administration in decompensated cirrhosis (ANSWER): an
open-label randomised trial.

Caraceni P(1), Riggio O(2), Angeli P(3), Alessandria C(4), Neri S(5), Foschi
FG(6), Levantesi F(7), Airoldi A(8), Boccia S(9), Svegliati-Baroni G(10),
Fagiuoli S(11), Romanelli RG(12), Cozzolongo R(13), Di Marco V(14), Sangiovanni
V(15), Morisco F(16), Toniutto P(17), Tortora A(18), De Marco R(19), Angelico
M(20), Cacciola I(21), Elia G(22), Federico A(23), Massironi S(24), Guarisco
R(25), Galioto A(26), Ballardini G(27), Rendina M(28), Nardelli S(2), Piano S(3),
Elia C(4), Prestianni L(5), Cappa FM(6), Cesarini L(8), Simone L(9), Pasquale
C(2), Cavallin M(3), Andrealli A(4), Fidone F(5), Ruggeri M(29), Roncadori A(30),
Baldassarre M(1), Tufoni M(1), Zaccherini G(1), Bernardi M(31); ANSWER Study
Investigators.

Collaborators: Domenicali M, Giannone FA, Merli M, Gioia S, Fasolato S, Sticca A,
Campion D, Risso A, Saracco GM, Maiorca D, Rizzotto A, Lanzi A, Neri E, Visani A,
Mastroianni A, Alberti AB, Mazzarelli C, Vangeli M, Marzioni M, Capretti F,
Kostandini A, Magini G, Colpani M, Laffi G, Gabbani T, Marsico M, Zappimbulso M, 
Petruzzi J, Calvaruso V, Parrella G, Caporaso N, Auriemma F, Guarino M, Pugliese 
F, Gasbarrini A, Leo P, De Leonardis F, Pecchioli A, Rossi P, Raimondo G, Negri
E, Dallio M, Loguercio C, Conte D, Celli N, Bringiotti R, Castellaneta NM,
Salerno F.

Author information: 
(1)Department of Medical and Surgical Sciences, and Center for Applied Biomedical
Research, University of Bologna, Bologna, Italy.
(2)Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy.
(3)Unit of Internal Medicine and Hepatology, Department of Medicine, University
of Padua, Padua, Italy.
(4)Division of Gastroenterology and Hepatology, Città della Salute e della
Scienza Hospital, University of Turin, Turin, Italy.
(5)Department of Clinical and Experimental Medicine, University of Catania,
Catania, Italy.
(6)Internal Medicine, Hospital of Faenza, Azienda Unità Sanitaria Locale of
Romagna, Faenza, Italy.
(7)Internal Medicine, Hospital of Bentivoglio, AUSL of Bologna, Bologna, Italy.
(8)Liver Unit, Department of Hepatology and Gastroenterology, Niguarda Hospital, 
Milan, Italy.
(9)Gastroenterology Unit, University Hospital, Ferrara, Italy.
(10)Department of Gastroenterology, Polytechnic University of Marche, Ancona,
Italy.
(11)Gastroenterology and Transplant Hepatology, Papa Giovanni XXIII Hospital,
Bergamo, Italy.
(12)Department of Experimental and Clinical Medicine, University of Florence,
Florence, Italy.
(13)Division of Gastroenterology, National Institute of Gastroenterology S De
Bellis, Castellana Grotte (Bari), Italy.
(14)Unit of Gastroenterology and Hepatology, Biomedical Department of Internal
and Specialistic Medicine, University of Palermo, Palermo, Italy.
(15)Azienda Ospedaliera di Rilievo Nazionale dei Colli, Cotugno Hospital of
Naples, Naples, Italy.
(16)Gastroenterology Unit, Department of Clinical Medicine and Surgery, Federico 
II University of Naples, Naples, Italy.
(17)Internal Medicine, Department of Medical Area, University of Udine, Udine,
Italy.
(18)Gastroenterology, Gemelli Foundation, Catholic University, Rome, Italy.
(19)Gastroenterology Unit, Hospital of Cosenza, Cosenza, Italy.
(20)Liver Unit, Tor Vergata University, Rome, Italy.
(21)Division of Clinical and Molecular Hepatology, University Hospital of
Messina, Messina, Italy.
(22)Infectious Diseases and Hepatology, University Hospital of Parma, Parma,
Italy.
(23)Department of Clinical and Experimental Internal Medicine, University of
Campania Luigi Vanvitelli, Naples, Italy.
(24)Gastroenterology and Endoscopy Unit, Foundation Istituto di Ricovero e Cura a
Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
(25)Internal Medicine, S Sebastiano General Hospital, Frascati (Rome), Italy.
(26)Internal Medicine, Hospital of Dolo, Azienda Unità Locale Socio-sanitaria
Serenissima, Mestre, Italy.
(27)Internal Medicine, Hospital of Rimini, AUSL of Romagna, Rimini, Italy.
(28)Section of Gastroenterology, Department of Emergency and Organ
Transplantation, University of Bari, Bari, Italy.
(29)Graduate School of Health Economics and Management, Catholic University,
Rome, Italy.
(30)Cineca Interuniversity Consortium, Bologna, Italy.
(31)Department of Medical and Surgical Sciences, and Center for Applied
Biomedical Research, University of Bologna, Bologna, Italy. Electronic address:
mauro.bernardi@unibo.it.

Erratum in
    Lancet. 2018 Aug 4;392(10145):386.

Comment in
    Lancet. 2018 Jun 16;391(10138):2391-2392.
    Lancet. 2018 Nov 3;392(10158):1623-1624.
    Lancet. 2018 Nov 3;392(10158):1623.
    Turk J Gastroenterol. 2019 Apr;30(4):385-386.

BACKGROUND: Evidence is scarce on the efficacy of long-term human albumin (HA)
administration in patients with decompensated cirrhosis. The human Albumin for
the treatmeNt of aScites in patients With hEpatic ciRrhosis (ANSWER) study was
designed to clarify this issue.
METHODS: We did an investigator-initiated multicentre randomised, parallel,
open-label, pragmatic trial in 33 academic and non-academic Italian hospitals. We
randomly assigned patients with cirrhosis and uncomplicated ascites who were
treated with anti-aldosteronic drugs (≥200 mg/day) and furosemide (≥25 mg/day) to
receive either standard medical treatment (SMT) or SMT plus HA (40 g twice weekly
for 2 weeks, and then 40 g weekly) for up to 18 months. The primary endpoint was 
18-month mortality, evaluated as difference of events and analysis of survival
time in patients included in the modified intention-to-treat and per-protocol
populations. This study is registered with EudraCT, number 2008-000625-19, and
ClinicalTrials.gov, number NCT01288794.
FINDINGS: From April 2, 2011, to May 27, 2015, 440 patients were randomly
assigned and 431 were included in the modified intention-to-treat analysis. 38 of
218 patients died in the SMT plus HA group and 46 of 213 in the SMT group.
Overall 18-month survival was significantly higher in the SMT plus HA than in the
SMT group (Kaplan-Meier estimates 77% vs 66%; p=0·028), resulting in a 38%
reduction in the mortality hazard ratio (0·62 [95% CI 0·40-0·95]). 46 (22%)
patients in the SMT group and 49 (22%) in the SMT plus HA group had grade 3-4
non-liver related adverse events.
INTERPRETATION: In this trial, long-term HA administration prolongs overall
survival and might act as a disease modifying treatment in patients with
decompensated cirrhosis.
FUNDING: Italian Medicine Agency.

Copyright © 2018 Elsevier Ltd. All rights reserved.

DOI: 10.1016/S0140-6736(18)30840-7 
PMID: 29861076  [Indexed for MEDLINE]