Randomized cross-over trial comparing albumin and frusemide infusions in nephrotic syndrome

Abstract

The contribution of hypoalbuminemia to impaired diuretic responsiveness can be overcome by administering larger doses of loop diuretics. However, the clinical efficacy of the combination of loop-acting diuretics with human albumin remains controversial. In the study reported here, 16 children with nephrotic syndrome and refractory edema were randomized in a cross-over trial to receive either the combination of 20% human albumin and frusemide infusion (HA+FU infusion group) or frusemide infusion alone (FU infusion group). At the end of study, median urine volume was 3.27 [95% confidence interval (CI) 2.04-4.50] ml/kg per hour in the HA+FU infusion group and 1.33 (95% CI 0.79-1.88) ml/kg per hour in the FU infusion group (P = 0.01); the median daily sodium excretion was 58 (95% CI 30-366) mEq and 30 (95% CI 10-122) mEq (P = 0.08), respectively The changes in other variables included weight loss [HA+FU 5.2% (95% CI 3.1-8.8); FU 0.8% (95% CI -1.9 to 4.1); P = 0.006]; urine osmolality [HA+FU 315 (95% CI 220-426) mOsm/kg; FU 368 (95% CI 318-446) mOsm/kg; P = 0.13]; osmolal clearance [HA+FU 1600 (95% CI 916-4140) ml/day; FU 880 (95% CI 510-2105) ml/day; P = 0.01; free water clearance [HA+FU -190 (95% CI -960 to 280) ml/day; FU -162 (95% CI -446 to -70) ml/day; P = 0.18]. The findings from this study suggest that the co-administration of albumin and frusemide infusions is more effective than the administration of frusemide infusion alone in inducing diuresis and natriuresis in patients with nephrotic syndrome.

Clinical practice guideline for pediatric idiopathic nephrotic syndrome 2013: general therapy

“…Combination therapy of human albumin with diuretic agents can enhance the elimination of sodium and fluids. In previous studies, the combination of furosemide with human albumin was associated with a two-fold increase in urine volume, compared with furosemide monotherapy [28][29][30]. Understanding the side effects of the therapy is also required.…”

The Efficacy of Tolvaptan in Congestive Heart Failure Patients with and Without Hypoalbuminemia: A Pilot Study

“…As loop diuretics are 91-99% bound to serum albumin avoiding the glomerular filtration in the nephron, hypoalbuminemia decreases the amount of loop diuretics to be delivered to the site of action in the thick ascending limb of Henle's loop [6]. Some reports showed that patients with hypoalbuminemia (serum albumin level of around <2.5-3.0 g/dL) do not sufficiently respond to loop diuretics such as furosemide [7,8].…”

Economic evaluation of human albumin use in patients with nephrotic syndrome in four Brazilian public hospitals: pharmacoeconomic study

“…It has been suggested in the literature that institutionalization and dissemination of guidelines or protocols in itself does not necessarily translate into changes in practices or into lasting clinical results. 21 Data from one study have shown that it takes five to ten years to achieve significant results from changes in practice after implementation of these instruments. 36 The process of establishing therapeutic guidelines should also be followed by continuing education, review of processes and monitoring of practices.…”