Human albumin administration in critically ill patients: systematic review of randomised controlled trials   Why albumin may not work

Abstract

Objective: To quantify effect on mortality of administering human albumin or plasma protein fraction during management of critically ill patients. Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. Subjects: 30 randomised controlled trials including 1419 randomised patients. Main outcome measure: Mortality from all causes at end of follow up for each trial. Results: For each patient category the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death after albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia it was 1.69 (1.07 to 2.67). Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.

The Evaluation of Albumin Use in an Iranian University Hospital

“…Some protocols indicate that albumin could be recommended for malnourished patients if: there Pharmaceutical Sciences, September 2016, 22, 186-189 | 189 is severe diarrhea (>2 l/day), serum albumin concentration <2 g/dl, diarrhea has not been cured by short-chain peptides or elemental formulas, and other reasons for diarrhea have been excluded. 11,12 None of the 52 patients in this study met these criteria, yet physicians prescribed albumin. The importance of DUEs is to illustrate the patterns of albumin utilization of different institutions, and thereby, future approaches to decision-making will be obtained.…”

“…9 It has been shown that hypoalbuminemia is associated with poor outcomes in critically ill patients. 9,12 Nevertheless, several studies have demonstrated that albumin administration in hypoalbuminemic patients had no distinctive effect on mortality or morbidity. 12 Thus, in many guidelines, decreased serum albumin concentration as a sole diagnosis is not considered a sufficient reason for albumin replacement.…”

“…9,12 Nevertheless, several studies have demonstrated that albumin administration in hypoalbuminemic patients had no distinctive effect on mortality or morbidity. 12 Thus, in many guidelines, decreased serum albumin concentration as a sole diagnosis is not considered a sufficient reason for albumin replacement. A useful practice for these patients is to identify and treat the underlying causes of the hypoalbuminemia.…”

“…6,11 Conversely, there are some guidelines that indicate albumin can be prescribed only in cases where the serum albumin level is less than 2.5g/dl. 12 In the current study, a total of 57 patients receiving albumin infusions just for hypoalbuminemia were considered to have been inappropriately treated. From all studied hypoalbuminemic patients, 15 cases with albumin levels between 2-2.5 g/dl, 13 cases with albumin levels >2.5 g/dl, and 29 patients with albumin levels >3.5 g/dl received albumin infusion just to prevent the possibility of developing hypoalbuminemia.…”

Evaluating the appropriateness of blood component utilization in burns patients

“…Thus albumin inhibits platelet aggregation and enhances inhibition of factor Xa by AntiThrombin III. 37 In India, the price of 20% human albumin was 4904 rupees. But ever since the Indian Drug Price Control Order (DPCO) 2013 by National Pharmaceutical Pricing Authority (NPPA) brought it under essential drug list, there has been a shortage for human albumin solutions.…”