The Age(s) Old Albumin Debate: Evidenced Based Albumin Repletion

Hi All, in report a few days ago, we talked about the age old debate about albumin vs. crystalloid. I did (probably too much) reading up on this and am going to summarize where the data exists for use albumin repletion. Disclaimer – this is probably not an exhaustive list, but the best I could do!

Take Home Points: Evidenced Based Albumin Repletion

In summary, there are three well-evidence based indications for use of albumin, and they’re all in cirrhosis:

  1. Prevention of post-paracentesis circulatory dysfunction (PPCD) – originally showed to reduce incidence of renal impairment and severe hyponatremia following large volume paracentesis compared to no albumin. Has since been shown to be superior to other colloid or crystalloid in preventing PPCD.
  1. Prevention of renal impairment in cirrhotics with SBP– landmark NEJM study in 1999 demonstrating reduced incidence of renal impairment and death with use of albumin + antibiotics for SBP, compared to antibiotics alone.
  1. Diagnosis and treatment of hepatorenal syndrome– many studies dating back to 1998 showed improved recovery of renal function with the use of albumin + a vasoconstrictor (terlipressin is the most well studied, but midodrine+octreotide or norepinephrine have also been studied) in Type 1 HRS.No definitive data supports this approach in Type 2 HRS.

* The remainder of practices – including the effect of albumin repletion in hypo vs normoalbuminemic cirrhotics, and the use of albumin for cirrhotics with non-SBP infections, has either not been shown to improve outcomes or has not been studied.

What about the use of albumin vs. crystalloid in critical illness??

  • First reviewed by BMJ meta-analysis in 1998/ Cochrane review that suggested albumin did not improve outcomes and may actually increase mortality. Flaw was multiple formulations of albumin included and multiple types of shock (trauma, sepsis, burns).
  • Subsequent Annals of Internal Medicine meta-analysis including only studies of purified albumin in critically ill and non-critically ill patients found albumin not superior to crystalloid, but concluded it was unknown if there was benefit in critically ill patients alone.
  • Large, double-blinded RCT of albumin vs saline for resuscitation of critically ill patients (SAFE study, NEJM 2004) found NO DIFFERENCE between the two groups with respect to: mortality, new organ failure, days in the ICU/hospital, or days of CRRT.
  • Additional smaller studies have been done in certain groups of patients (trauma, sepsis, etc) but no convincing evidence of benefit of albumin has yet been demonstrated in critically ill patients!

Go forth and spread the evidenced based practice!

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