Albumin administration in the acutely ill: what is new and where next?

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Abstract

Albumin solutions have been used worldwide for the treatment of critically ill patients since they became commercially available in the 1940s. However, their use has become the subject of criticism and debate in more recent years. Importantly, all fluid solutions have potential benefits and drawbacks. Large multicenter randomized studies have provided valuable data regarding the safety of albumin solutions, and have begun to clarify which groups of patients are most likely to benefit from their use. However, many questions remain related to where exactly albumin fits within our fluid choices. Here, we briefly summarize some of the physiology and history of albumin use in intensive care before offering some evidence-based guidance for albumin use in critically ill patients.

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Most cited references 59

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Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults.

Nor'azim Mohd Yunos, Rinaldo Bellomo, Colin Hegarty … (2012)

Administration of traditional chloride-liberal intravenous fluids may precipitate acute kidney injury (AKI). To assess the association of a chloride-restrictive (vs chloride-liberal) intravenous fluid strategy with AKI in critically ill patients. Prospective, open-label, sequential period pilot study of 760 patients admitted consecutively to the intensive care unit (ICU) during the control period (February 18 to August 17, 2008) compared with 773 patients admitted consecutively during the intervention period (February 18 to August 17, 2009) at a university-affiliated hospital in Melbourne, Australia. During the control period, patients received standard intravenous fluids. After a 6-month phase-out period (August 18, 2008, to February 17, 2009), any use of chloride-rich intravenous fluids (0.9% saline, 4% succinylated gelatin solution, or 4% albumin solution) was restricted to attending specialist approval only during the intervention period; patients instead received a lactated solution (Hartmann solution), a balanced solution (Plasma-Lyte 148), and chloride-poor 20% albumin. The primary outcomes included increase from baseline to peak creatinine level in the ICU and incidence of AKI according to the risk, injury, failure, loss, end-stage (RIFLE) classification. Secondary post hoc analysis outcomes included the need for renal replacement therapy (RRT), length of stay in ICU and hospital, and survival. RESULTS Chloride administration decreased by 144 504 mmol (from 694 to 496 mmol/patient) from the control period to the intervention period. Comparing the control period with the intervention period, the mean serum creatinine level increase while in the ICU was 22.6 μmol/L (95% CI, 17.5-27.7 μmol/L) vs 14.8 μmol/L (95% CI, 9.8-19.9 μmol/L) (P = .03), the incidence of injury and failure class of RIFLE-defined AKI was 14% (95% CI, 11%-16%; n = 105) vs 8.4% (95% CI, 6.4%-10%; n = 65) (P <.001), and the use of RRT was 10% (95% CI, 8.1%-12%; n = 78) vs 6.3% (95% CI, 4.6%-8.1%; n = 49) (P = .005). After adjustment for covariates, this association remained for incidence of injury and failure class of RIFLE-defined AKI (odds ratio, 0.52 [95% CI, 0.37-0.75]; P <.001) and use of RRT (odds ratio, 0.52 [95% CI, 0.33-0.81]; P = .004). There were no differences in hospital mortality, hospital or ICU length of stay, or need for RRT after hospital discharge. CONCLUSION The implementation of a chloride-restrictive strategy in a tertiary ICU was associated with a significant decrease in the incidence of AKI and use of RRT. Clinicaltrials.gov Identifier: NCT00885404.

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Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.

P Sort, M Navasa, V Arroyo … (1999)

In patients with cirrhosis and spontaneous bacterial peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. We randomly assigned 126 patients with cirrhosis and spontaneous bacterial peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in dosages that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. In patients with cirrhosis and spontaneous bacterial peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone.

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Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis.

Alexander Gerbes, Francesco G Salerno, Pere Ginès … (2007)

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Author and article information

Contributors

Jean-Louis Vincent

James A Russell

Matthias Jacob

Greg Martin

Bertrand Guidet

Jan Wernerman

Ricard Ferrer Roca

Stuart A McCluskey

Luciano Gattinoni

Journal

Journal ID (nlm-ta): Crit Care

Journal ID (iso-abbrev): Crit Care

Title: Critical Care

Publisher: BioMed Central

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Print): 2014

Publication date (Electronic): 16 July 2014

Publication date PMC-release: 16 July 2015

Volume: 18

Issue: 4

Page: 231

Affiliations

[1 ]Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, route de Lennik 808, 1070 Brussels, Belgium

[2 ]Center for Heart Lung Innovation and Critical Care Medicine, University of British Columbia and St. Paul's Hospital, Vancouver, Canada V6Z BC

[3 ]Department of Anaesthesiology, University Hospital Munich, Nussbaumstraße 20, 80336 Munich, Germany

[4 ]Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA 30303, USA

[5 ]Service Réanimation Médicale, Hôpital Saint Antoine, Universitaires Est Parisien, Paris, France

[6 ]Sorbonne Universités, UPMC Université Paris 06, UMR-S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, F-75013 Paris, France

[7 ]Department of Anesthesiology & Intensive Care Medicine, Karolinska University Hospital, Huddinge, 14186 Stockholm, Sweden

[8 ]Servei de Medicina Intensiva, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, CIBER Enfermedades Respiratorias, 08221 Terrassa, Barcelona, Spain

[9 ]Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada M5G 2C4

[10 ]Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda – Ospedale Maggiore Policlinico, 20122 Milan, Italy

Article

Publisher ID: cc13991

DOI: 10.1186/cc13991

PMC ID: 4223404

PubMed ID: 25042164

SO-VID: 7460c08f-921e-4c6b-ba84-667b468d2c0c

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Albumin administration in the acutely ill: what is new and where next?

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Most cited references 59

Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults.

Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.

Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis.

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