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Albumin

Albumin. Tiffany T. Nguyen PGY2 April 2014. Introduction. Human serum albumin is available in 5% and 25%. Both isotonic [Na] 130 to 160 mEq/L (mmol/L). The 5 percent solution provides five times the sodium load of the 25 percent solution.

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Albumin

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  1. Albumin Tiffany T. Nguyen PGY2 April 2014

  2. Introduction • Human serum albumin is available in 5% and 25%. • Both isotonic [Na] 130 to 160 mEq/L (mmol/L). • The 5 percent solution provides five times the sodium load of the 25 percent solution. • The 25 percent solution is typically given if the patient is hypervolemic, whereas the 5 percent solution is given if dehydration is suspected

  3. Indications • Spontaneous Bacterial Peritonitis (Salerno F, et al.Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol. 2013 Feb;11(2):123-30.e1. doi: 10.1016/j.cgh.2012.11.007. Epub 2012 Nov 22.) • Hepatorenal syndrome (Duvoux C, et al. Effects of noradrenalin and albumin in patients with type I hepatorenal syndrome: a pilot study. Hepatology. 2002 Aug;36(2):374-80.) • Adjunct to large volume paracentesis (>5L) in treatment of diuretic-resistant ascites in cirrhosis. (Bernardi M, et al. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012 Apr;55(4):1172-81. doi: 10.1002/hep.24786.) • Therapeutic plasma exchange and/or plasmapheresis.

  4. What about resuscitation in shock? • Some clinician advocate albumin solution over isotonic saline solution due to 2 advantages: • Rapid plasma volume expansion, since colloid solution remains in vascular space. • Lesser risk of pulmonary edema due to dilutional hypoalbuminuria will not occur.

  5. But … • Multiple randomized trials and meta-analyses failed to demonstrate benefits. • A well-executed multicenter trial randomly assigned nearly 7000 hypovolemic medical and surgical ICU patients to fluid resuscitation colloid and crystalloid. All-cause mortality at 28 days, multiorgan failure, the duration of hospitalization, and effect upon systemic pH were similar in both groups. (Finfer S, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350(22):2247.) • Meta-analysis of 55 studies, 3000 critically ill patients. No evidence of improved outcomes or increased mortality with albumin. Subset analysis identified no group of patients (trauma, burns, hypoalbuminemia, or ascites) that had statistically significant benefit or harm from albumin transfusion. (Wilkes MM, et al. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med. 2001;135(3):149.)

  6. More recently … • CRISTAL randomized trial is a nine-year, multicenter, open-label trial. (Annane D, et al. 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.) • No difference in 28-day mortality between colloids vs crystalloids. However, Colloids had more days free of mechanical ventilation (13.5 vs 14.6 days) and vasopressor therapy (15.2 vs 16.2 days), as well as a lower 90-day mortality (31 vs 34 percent). • Confidence of benefit was limited by open-label design, lengthy study period, and heterogeneity of fluids that were compared between the groups. • Caironi P, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014 Apr 10;370(15):1412-21. • In patients with severe sepsis, albumin replacement in addition to crystalloids, as compared with crystalloids alone, did not improve the rate of survival at 28 and 90 days.

  7. What about diuretics with albumin for refractory edema? • Nephrotic syndrome • Study in patient with nephrotic syndrome (serum albumin 3g/dL), loop diuretic and albumin only produce modest increase in sodium excretion vs diuretic alone. • Cirrhosis • Similar lack of efficacy seen in patient with cirrhosis. Combination vs lasix alone did not increase rate of lasix or sodium excretion. • Severe hypoalbuminuria • No study done so far to look at combination therapy vs lasix alone in serum albumin <2g/dL.

  8. UCI Medical Center March 2014

  9. UCI Medical Center March 2014

  10. Internal Medicine

  11. Surgery

  12. Most Common Reasons • Medicine • Combine with diuretic for third spacing (cirrhosis, nephrotic syndrome, heart failure) • Severe sepsis • Surgery • Overnight hypotension • Low urine output • Neurology • Septic shock • Hypoalbuminemia • Family • Severe sepsis

  13. Cost Analysis

  14. Thank You Question?

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