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 2014Total Patients and Albumin Order for March 2014 by Specialty

0

20

40

60

80

100

120

140

160

Patient Order

Patient 55 47 9 2 1

Order 140 108 29 3 1

Medicine Surgery Neurology Family ED

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

0

20

40

60

80

100

120

140

Evidence Based No Strong Evidence

Evidence Based 18 9 1 0 1

No Strong Evidence 122 99 16 3 0

Medicine Surgery Neurology Family ED

Internal MedicineAlbumin Orders for March 2014

INTERNAL MEDICINE

0

10

20

30

40

50

60

70

80

Evidence Based No Strong Evidence

Evidence Based 14 4 0

No Strong Evidence 74 43 5

Wards Medical ICU Cardiology

SurgeryAlbumin Orders for March 2014

SURGERY

0

2

4

6

8

10

12

14

16

18

Indicated Not Indicated

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

Neuro surg

Ortho Burn CTColo

rectalGen

Hepato biliary

OncTrans plant

Trauma Vasc Uro ENT

Most Common Reasons Medicine

1. Combine with diuretic for third spacing (cirrhosis, nephrotic syndrome, heart failure)

2. Severe sepsis

Surgery1. Overnight hypotension2. Low urine output

Neurology1. Septic shock2. Hypoalbuminemia

Family1. Severe sepsis

Cost Analysis25% Albumin 5% Albumin Total

Expense

$22.02 per 20ml

$38.12 per 50ml

$23.61 per 50ml

$38.40 per 250ml

$77.87 per 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

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