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
Patient
O rde r

Medicine

Surge ry

Ne urology

Fam ily

ED

55
140

47
108

9
29

2
3

1
1

Patie nt

O rde r

UCI Medical Center March 2014

Albumin Orders for March 2014 by Specialty
140
120
100
80
60
40
20
0
Evide nce Base d
No Strong Evidence

Medicine

Surge ry

Neurology

Fam ily

ED

18
122

9
99

1
16

0
3

1
0

Evide nce Base d

No Strong Evidence

Internal Medicine
Albumin Orders for March 2014
INTERNAL MEDICINE
80
70
60
50
40
30
20
10
0
Evide nce Base d
No Strong Evidence

W ards

Me dical IC U

C ardiology

14
74

4
43

0
5

Evide nce Base d

No Strong Evidence

Surgery
Albumin Orders for March 2014
SURGERY
18
16
14
12
10
8
6
4
2
0
Neuro
surg

Ortho

Burn

CT

Colo
rectal

Gen

Hepato
biliary

Onc

Indicated

Not Indicated

15

17

Indicated

Trans
Trauma
plant

Not Indicated

Vasc

Uro

ENT

13

Most Common Reasons

Medicine
1.
2.

Combine with diuretic for third spacing (cirrhosis, nephrotic

syndrome, heart failure)
Severe sepsis

Surgery
1.
2.

Overnight hypotension
Low urine output

Neurology
1.
2.

Septic shock
Hypoalbuminemia

Family
1.

Severe sepsis

Cost Analysis
25% Albumin
$22.02 per
20ml

5% Albumin

$38.12 per
50ml

$23.61 per
50ml

Total Expense

$38.40 per
250ml

$77.87 per
500ml

Medicine

551

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?