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.
The 25 percent solution is typically given if the
patient is hypervolemic, whereas the 5 percent
solution is given if dehydration is suspected
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.
What about resuscitation in shock?
Some clinician advocate albumin solution
over isotonic saline solution due to 2
advantages:
1. Rapid plasma volume expansion, since colloid
solution remains in vascular space.
2. Lesser risk of pulmonary edema due to dilutional
hypoalbuminuria will not occur.
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.)
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.
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.
UCI Medical Center March 2014
Total Patients and Albumin Order for March 2014 by Specialty

160

140

120

100

80

60

40

20

0
Medicine Surgery Neurology Family ED
Pat ient 55 47 9 2 1
Order 140 108 29 3 1

Pat ient Order

UCI Medical Center March 2014
Albumin Orders for March 2014 by Specialty

140

120

100

80

60

40

20

0
Medicine Surgery Neurology Family ED
Evidence Based 18 9 1 0 1
No St rong Evidence 122 99 16 3 0

Evidence Based No St rong Evidence

Internal Medicine
Albumin Orders for March 2014
INTERNAL MEDICINE

80

70

60

50

40

30

20

10

0
Wards Medical ICU Cardiology
Evidence Based 14 4 0
No St rong Evidence 74 43 5

Evidence Based No St rong Evidence

Surgery
Albumin Orders for March 2014
SURGERY

18

16

14

12

10

0
Neuro Colo Hepato Trans
Ort ho Burn CT Gen Onc Trauma Vasc Uro ENT
surg rectal biliary plant

Indicated 4 0 0 0 1 5 0 0 3 0 0 0 0
Not Indicated 9 2 7 15 8 1 17 1 0 13 7 3 2

Indicated Not Indicated

Most Common Reasons
Medicine
1. Combine with diuretic for third spacing (cirrhosis, nephrotic
syndrome, heart failure)
2. Severe sepsis
Surgery
1. Overnight hypotension
2. Low urine output
Neurology
1. Septic shock
2. Hypoalbuminemia
Family
1. Severe sepsis
Cost Analysis
25% Albumin 5% Albumin Total Expense

$22.02 per $38.12 per $23.61 per $38.40 per $77.87 per
20ml 50ml 50ml 250ml 500ml
Medicine 551 3 38 $ 24,078.38

Surgery 97 47 21 $ 7,137.71

Neurology 87 20 $ 4873.84

Family 10 $ 381.20

ED $0

March 04 $ 36,471.13

?Annual $ 437,653.56
Thank You

Question?