Albumin

Indications for Albumin Administration

Acute Respiratory Distress Syndrome (ARDS)

  • Clinical Efficacy
    • Systematic Review and Meta-Analysis of Albumin in ARDS (Crit Care, 2014) [MEDLINE]
      • Albumin Improved Oxygenation, But Did Not Impact the Mortality Rate: randomized controlled trials are needed

Burns (see Burns, [[Burns]])

  • xxx

Cirrhosis (see End-Stage Liver Disease, [[End-Stage Liver Disease]])

  • xxxx

Large Volume Paracentesis (see Paracentesis, [[Paracentesis]])

  • Clinical Efficacy
    • Randomized Trial Comparing Albumin, Dextran 70, and Polygeline in Cirrhosis with Ascites Treated by Paracentesis (Gastroenterology, 1996) [MEDLINE]: post-paracentesis circulatory dysfunction is not spontaneously reversible and is associated with a shorter time to first readmission and shorter survival
      • Albumin is the best plasma expander to prevent this complication

Spontaneous Bacterial Peritonitis (SBP) (see Spontaneous Bacterial Peritonitis, [[Spontaneous Bacterial Peritonitis]])

  • Clinical Efficacy
    • Trial of Albumin in Cirrhosis with SBP (NEJM, 1999) [MEDLINE]
      • In Combination with Antibiotics, Albumin Decreased Mortality Rate and the Prevalence of Renal Impairment

Intravenous Fluid Resuscitation in Sepsis (see Sepsis, [[Sepsis]])

  • Clinical Efficacy
    • SAFE Trial: Comparing Crystalloid (Normal Saline) vs Colloid (4% Albumin) in Heterogenous Population of ICU Patients (NEJM, 2004) [MEDLINE]
      • No Difference in 28-Day Mortality or Need for Hemodialysis
      • Traumatic Brain Injury (TIB) Subgroup: Colloid Use Increased the Mortality Rate (see Traumatic Brain Injury, [[Traumatic Brain Injury]])
      • Colloid Use in Septic Shock Subgroup Demonstrated a Trend Toward Lower Mortality Rate
    • ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient (Am J Respir Crit care Med, 2010) [MEDLINE]
      • Hyper-Oncotic Fluids (Hydroxyethyl Starch, Dextrans, 20-25% Albumin) are Not Recommended, Due to Their Risk of Renal Dysfunction
      • Hypo-Oncotic Colloids (5% Albumin) are as Effective as Crystalloids
    • Systematic Review/Meta-Analysis of Albumin in Sepsis (Crit Care Med, 2011) [MEDLINE]
      • Albumin-Containing Solutions Were Associated with Lower Mortality Than Other Fluid Resuscitation Regimens in Sepsis
    • Study of Chloride-Restrictive IV Fluid Resuscitation Strategy in Critically Ill Patients (JAMA, 2012) [MEDLINE]: study is based on the observation that hyperchloremia may induce renal vasoconstriction
      • Chloride-Restrictive IV Fluid Resuscitation Strategy Decreased Incidence of Acute Kidney Injury and Use of Hemodialysis
      • Chloride-Restrictive IV Fluid Resuscitation Strategy Demonstrated No Difference in Hospital Mortality, Hspital or ICU Length of Stay, or Need for Hemodialysis After Hospital Discharge
    • CRISTAL Trial (JAMA, 2013) [MEDLINE]
      • 28-Day Mortality: no difference between use of crystalloid vs colloid in septic shock
      • 90-Day Mortality: improved with use of colloids (although authors note that these findings need to be confirmed in future trials)
    • Fluids in Sepsis and Septic Shock Group Study (Ann Intern Med, 2014) [MEDLINE]: network meta-analysis (14 studies, n = 18,916 patients)
      • Network Meta-Analysis at the 4-Node Level: higher mortality with starches than with crystalloids (high confidence)
      • Network Meta-Analysis at the 4-Node Level: lower mortality with albumin than with crystalloids (moderate confidence) or starches (moderate confidence)
      • Network Meta-Analysis at the 6-Node Level: lower mortality with albumin than with saline (moderate confidence) and low-molecular-weight starch (low confidence) and with balanced crystalloids than with saline (low confidence) and low and high-molecular-weight starches (moderate confidence)
      • Conclusions: resuscitation with balanced crystalloids (lactated ringers, etc) or albumin was associated with decreased mortality, as compared to other fluids
    • Italian ALBIOS Study of Albumin in Severe Sepsis (NEJM, 2014) [MEDLINE]
      • Albumin in Addition to Crystalloids Did Not Improve the 28-Day and 90-Day Survival, as Compared to Crystalloid Alone

Contraindications

Traumatic Brain Injury (TBI) (see Traumatic Brain Injury, [[Traumatic Brain Injury]])

  • Clinical Efficacy
    • SAFE Trial: Comparing Crystalloid (Normal Saline) vs Colloid (4% Albumin) in Heterogenous Population of ICU Patients (NEJM, 2004) [MEDLINE]
      • No Difference in 28-Day Mortality or Need for Hemodialysis
      • Traumatic Brain Injury (TIB) Subgroup: Colloid Use Increased the Mortality Rate (see Traumatic Brain Injury, [[Traumatic Brain Injury]])
      • Colloid Use in Septic Shock Subgroup Demonstrated a Trend Toward Lower Mortality Rate

Albumin Physiology/Pharmacology

Hepatic Albumin Synthesis

  • Albumin Enters the Vascular Space Via Direct Entry from Hepatocytes into the Sinusoids (Traversing the Space of Disse) and By Entry into the Hepatic Lymphatics (Moving into the Thoracic Duct)

Determinants of Serum Albumin Concentration

  • Rate of Albumin Synthesis
  • Amount of Albumin Secreted from Hepatocytes
  • Distribution of Albumin in Body Fluids
  • Rate of Albumin Degradation

Albumin in the Intravascular Space

  • Half-Life of Albumin in the Intravascular Space: 16 hrs
  • Etiology of Loss of Albumin from intravascular Space (ie: from the Plasma)

Albumin Degradation

  • Albumin Half-Life: 18-20 days
  • Albumin Degradation is Poorly Understood: it may be degraded within the endothelium of capiilaries, bone marrow, and liver sinuses
  • Age of Albumin Molecule: albumin degradation is random and it not related to age of the albumin molecule

Albumin Administration

  • Source: pooled from human plasma, heat pasteurized
  • IV
    • 5% Albumin (Plasmanate): 250-500 ml
    • 25% Albumin: 50 ml (contains 12.5 g albumin)
      • Draws approximately an additional 175 ml of fluid intravascularly within 15 min
    • 25% Albumin: 100 ml (contains 25g of albumin)

Adverse Effects of Albumin Administration

XXX

  • xxx

Other Adverse Effects

  • Hyperalbuminemia (see Hyperalbuminemia, [[Hyperalbuminemia]])
  • xxxx
  • xxxx
  • xxxx
  • xxxx

References

General

  • Use of 125-I- and 51-Cr-labeled albumin for the measurement of gastrointestinal and total albumin catabolism. J Clin Invest. Dec 1967;46(12):2064-82
  • Albumin synthesis (second of two parts). N Engl J Med. Apr 13 1972;286(15):816-21
  • Albumin synthesis. 1. N Engl J Med. Apr 6 1972;286(14):748-57
  • Alcohol, amino acids, and albumin synthesis. Gastroenterology. Dec 1974;67(6):1200-13
  • Serum albumin. Hepatology. Mar-Apr 1988;8(2):385-401
  • Serum albumin level on admission as a predictor of death, length of stay, and readmission. Arch Intern Med. Jan 1992;152(1):125-30
  • The change in serum protein concentration in response to the stress of total joint surgery: a comparison of older versus younger patients. J Am Geriatr Soc. May 1996;44(5):555-8
  • Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. Jan 1999;134(1):36-42
  • Low levels of plasma proteins: malnutrition or inflammation?. Clin Chem Lab Med. Feb 1999;37(2):91-6
  • The role of albumin in critical illness. Br J Anaesth 2000; 85:599-610 [MEDLINE]
  • Inflammation and dietary protein intake exert competing effects on serum albumin and creatinine in hemodialysis patients. Kidney Int. Jul 2001;60(1):333-40
  • Relationships among inflammation nutrition and physiologic mechanisms establishing albumin levels in hemodialysis patients. Kidney Int. Jun 2002;61(6):2240-9
  • Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials. Ann Surg. Mar 2003;237(3):319-34
  • Inflammation and reduced albumin synthesis associated with stable decline in serum albumin in hemodialysis patients. Kidney Int. Apr 2004;65(4):1408-15
  • Serum albumin: relationship to inflammation and nutrition. Semin Dial. Nov-Dec 2004;17(6):432-7
  • Admission serum albumin is predicitve of outcome in critically ill trauma patients. Am Surg. Dec 2004;70(12):1099-102
  • Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. Am J Clin Nutr. Aug 2004;80(2):299-307
  • Comparing outcome predictability of markers of malnutrition-inflammation complex syndrome in haemodialysis patients. Nephrol Dial Transplant. Jun 2004;19(6):1507-19
  • Hypoalbuminemia 3 months after hospital discharge: significance for long-term survival. J Am Geriatr Soc. Jul 2005;53(7):1222-6
  • Inhibition of albumin synthesis in chronic diseases: molecular mechanisms. J Clin Gastroenterol. Apr 2005;39(4 Suppl 2):S143-6
  • Hypoalbuminemia in renal failure: pathogenesis and therapeutic considerations. Kidney Blood Press Res. 2005;28(5-6):307-10
  • Revisiting mortality predictability of serum albumin in the dialysis population: time dependency, longitudinal changes and population-attributable fraction. Nephrol Dial Transplant. Sep 2005;20(9):1880-8
  • Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study. BMJ. Nov 18 2006;333(7577):1044
  • Quality indicators for the care of undernutrition in vulnerable elders. J Am Geriatr Soc. Oct 2007;55 Suppl 2:S438-42
  • Relevance of albumin in modern critical care medicine. Best Pract Res Clin Anaesthesiol. Jun 2009;23(2):183-91
  • Hypoalbuminemia in the first 24h of admission is associated with organ dysfunction in burned patients. Burns. Jun 7 2012
  • Risk factors for reintubation in the post-anaesthetic care unit: a case-control study. Br J Anaesth. Jul 9 2012

Use of Albumin in Acute Respiratory Distress Syndrome (ARDS)

  • Albumin versus crystalloid solutions in patients with the acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care 2014 [MEDLINE]

Use of Albumin in Ascites/Large Volume Paracentesis

  • Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis.  Gastroenterology 1996; 111:1002-1010 [MEDLINE]

Use of Albumin in Burns

  • Role of albumin in burnt patients: its efficacy during intensive care.  Ann Fr Anesth Reanim  1996; 15:1124-1129 [MEDLINE]

Use of Albumin in Traumatic Brain Injury (TBI)

  • Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. Aug 30 2007;357(9):874-84

Use of Albumin in Sepsis/Critical Illness

  • A paradigm for consensus. The University Hospital Consortium guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. Arch Intern Med. Feb 27 1995;155(4):373-9
  • Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. ALYSIS. Jul 25 1998;317(7153):235-40
  • Excess mortality after human albumin administration in critically ill patients. Clinical and pathophysiological evidence suggests albumin is harmful. BMJ. Jul 25 1998;317(7153):223-4
  • Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ. Mar 28 1998;316(7136):961-4
  • Debate: Albumin administration should be avoided in the critically ill. Crit Care. 2000;4(3):151-5
  • Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet. Mar 24 2001;357(9260):911-6
  • Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med. Aug 7 2001;135(3):149-64
  • Albumin administration–what is the evidence of clinical benefit? A systematic review of randomized controlled trials. Eur J Anaesthesiol. Oct 2003;20(10):771-93
  • SAFE Trial: A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247–2256 [MEDLINE]
  • Morbidity in hospitalized patients receiving human albumin: a meta-analysis of randomized, controlled trials. Crit Care Med. Oct 2004;32(10):2029-38
  • A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. May 27 2004;350(22):2247-56 [MEDLINE]
  • Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study. Crit Care Med. Oct 2006;34(10):2536-40
  • A survey of Canadian intensivists’ resuscitation practices in early septic shock. Crit Care. 2007;11(4):R74
  • Resuscitating patients with early severe sepsis: a Canadian multicentre observational study. Can J Anaesth. Oct 2007;54(10):790-8
  • Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. Jan 2008;34(1):17-60
  • Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. Jan 2008;36(1):296-327
  • An Official ATS/ERS/ESICM/SCCM/SRLF Statement:  Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine.  Am J Respir Crit Care Med  2010;  181:1128-1155.  DOI:  10.1164/rccm.200711-1664ST [MEDLINE]
  • Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. Nov 9 2011;CD001208 [MEDLINE]
  • The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Crit Care Med. 2011 Feb;39(2):386-91. doi: 10.1097/CCM.0b013e3181ffe217 [MEDLINE]
  • Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013 Nov 6;310(17):1809-17. doi: 10.1001/jama.2013.280502 [MEDLINE]
  • Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2014 Jul 22. doi: 10.7326/M14-0178 [MEDLINE]
  • ALBIOS Study. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014 Apr 10;370(15):1412-21. doi: 10.1056/NEJMoa1305727. Epub 2014 Mar 18 [MEDLINE]

Use of Albumin Spontaneous Bacterial Peritonitis

  • Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. N Engl J Med 1999;341:403-9 [MEDLINE]