Aligning policy and clinical guidelines for albumin use in cirrhosis: insights from Indonesia Hepatology Medical Workgroup Meeting.

Background: Cirrhosis continues to be a major health burden in Indonesia, with high mortality and morbidity related to complications including ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS). Although international guidelines strongly recommend albumin therapy for these complications, in Indonesia the adoption of international guidelines has been limited by universal healthcare policy and albumin indications defined in the National Formulary. The Indonesia Hepatology Medical Workgroup Meeting (December 2025) was convened to address barriers to the implementation of the newly launched National Cirrhosis Guideline, outline potential solutions, and discuss emerging topics such as long-term albumin (LTA) therapy and recombinant albumin (RA). Methods: Seven hepatology experts from tertiary care centers completed a pre-meeting survey and participated in structured discussions on local barriers to implementation of the National Cirrhosis Guideline, evolution of treatment towards LTA, and clinical considerations for RA. Results: The workgroup welcomed the National Cirrhosis Guideline for defining clear albumin indications in large-volume paracentesis (LVP), SBP, and HRS that align with international standards and should serve as the primary clinical guidance for management of cirrhosis in Indonesia. Cost-effectiveness evidence supports albumin use for SBP, HRS, and LVP; however, the current real-world management is still suboptimal. The primary barriers to implementation of the National Cirrhosis Guideline were the restricted indications and criteria defined within the National Formulary. The discussion indicated that albumin underutilization, lack of standardized care, and limited adoption of LTA treatment were primarily due to unclear patient selection criteria and dosing guidance. RA was recognized as a novel alternative, but concerns about long-term safety, immunogenicity, and functional equivalence persist. Conclusions: The National Cirrhosis Guideline represents a critical advancement toward standardized cirrhosis management in Indonesia. Immediate priorities include National Formulary alignment, hospital protocol integration, and clinician education to support evidence-based albumin utilization nationwide. While LTA offers potential disease-modifying benefits, its routine adoption remains constrained by economic and policy considerations, and it should be considered selectively when clinically appropriate. While RA may offer scalability and consistency, long-term safety, immunogenicity, and non-oncotic functional equivalence require further confirmation before routine clinical adoption.