Albumin Infusion in Critically Ill COVID-19 Patients: Hemodilution and Anticoagulation

Abstract

Hypercoagulation is one of the major risk factors for ICU treatment, mechanical ventilation, and death in critically ill patients infected with SARS-CoV-2. At the same time, hypoalbuminemia is one risk factor in such patients, independent of age and comorbidities. Especially in patients with severe SARS-CoV-2-infection, albumin infusion may be essential to improve hemodynamics and to reduce the plasma level of the main marker of thromboembolism, namely, the D-dimer plasma level, as suggested by a recent report. Albumin is responsible for 80% of the oncotic pressure in the vessels. This is necessary to keep enough water within the systemic circulatory system and for the maintenance of sufficient blood pressure, as well as for sufficient blood supply for vital organs like the brain, lungs, heart, and kidney. The liver reacts to a decrease in oncotic pressure with an increase in albumin synthesis. This is normally possible through the use of amino acids from the proteins introduced with the nutrients reaching the portal blood. If these are not sufficiently provided with the diet, amino acids are delivered to the liver from muscular proteins by systemic circulation. The liver is also the source of coagulation proteins, such as fibrinogen, fibronectin, and most of the v WF VIII, which are physiological components of the extracellular matrix of the vessel wall. While albumin is the main negative acute-phase protein, fibrinogen, fibronectin, and v WF VIII are positive acute-phase proteins. Acute illnesses cause the activation of defense mechanisms (acute-phase reaction) that may lead to an increase of fibrinolysis and an increase of plasma level of fibrinogen breakdown products, mainly fibrin and D-dimer. The measurement of the plasma level of the D-dimer has been used as a marker for venous thromboembolism, where a fourfold increase of the D-dimer plasma level was used as a negative prognostic marker in critically ill SARS-CoV-2 hospitalized patients. Increased fibrinolysis can take place in ischemic peripheral sites, where the mentioned coagulation proteins can become part of the provisional clot (e.g., in the lungs). Although critically ill SARS-CoV-2-infected patients are considered septic shock patients, albumin infusions have not been considered for hemodynamic resuscitation and as anticoagulants. The role of coagulation factors as provisional components of the extracellular matrix in case of generalized peripheral ischemia due to hypoalbuminemia and hypovolemia is discussed in this review.

Study of Albumin Oxidation in COVID-19 Pneumonia Patients: Possible Mechanisms and Consequences

“…Infusions of human albumin solution can reduce the more severe or life-threatening events that take place in COVID-19 patients [ 38 , 114 ]. However, there is no consensus as to whether simply administering albumin to patients with hypoalbuminemia reduces their morbidity and mortality [ 48 , 115 , 116 , 117 ].…”

The ability of D-dimer, albumin, and D-Dimer/albumin ratio to predict in-hospital mortality and intensive care unit admission in COVID-19 patients admitted to the emergency department

“…The literature indicates that hypoalbuminemia is associated with increased arterial and venous thrombosis risk in different clinical situations (16,17). Besides, a recent study has demonstrated that albumin infusion can be used to improve hemodynamics and decrease D-dimer plasma level, which is the main marker of thromboembolism, in critically ill COVID-19 patients (18).…”

The Prognostic Value of ADAMTS-13 and von Willebrand Factor in COVID-19 Patients: Prospective Evaluation by Care Setting

“…Thus, low albumin levels might be associated with thrombotic events in acutely ill patients, reflecting proinflammatory or hypercoagulable states [33]. In COVID-19 patients, as well as in other critical settings, low serum albumin is associated with poor outcomes [34][35][36], and albumin infusion has been suggested to be an effective treatment to improve prognosis in COVID-19 [37,38].…”