Albumin ~clinical indication

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Albumin clinical indication

• Speaker???
• 2003/2/10

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Mechanism of action/Effect

• Blood volume expander70 to 80 of the colloid
  oncotic pressure of plasma.
• AntihyperbilirubinemicAlbumin is a transport
  protein that reversibly binds both endogenous and
  exogenous substances including bilirubin fatty
  acids, hormones, enzymes, drugs, dyes, and trace
  metals

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Indications
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General Consideration

• The benefit of administration of albumin to
  seriously ill patients is currently
  controversial.

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• A meta-analysis of randomized, controlled
  clinical studies of albumin use revealed excess
  mortality of approximately 6 (i.e., 1 excess
  death per 17 treated patients)
• combined groups of patients with hypovolemia,
  burns, or hypoproteinemia who received albumin
  either instead of or in addition to crystalloid
  solutions. Also, for each of these patient
  subgroups, the risk of death in the
  albumin-treated group was higher than in the
  comparison group.
• BMJ 1998 317 235-40.

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????

• (1) ?????????????
• A.??????????????????????1000 mL????????????,???(he
  matocrit)gt30,????(hemoglobin)gt10
  gm/dL,?????????,???????????,?dextran?hydroxyethyls
  tarch?polyvinylpyrolidone??????????,???????,??????
  ?50 gm(86/1/1)?
• B. 70???????????????????????,???????????,?????????
  ???,???????50 gm?

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• (2) ??????????????????????
• A.????????? 2.5 gm/dL
• a.  ????(???????????)???????25gm?
• b. ?????(?????????????),???????25 gm?
• c. ??????
• d. ????

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• B.????????? 3.0 gm/dL
• a.   ???????????????,??????
• b.  ??????
• c.   ?????(gt40)
• C.?????????????,??? 37.5 gm?

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Accepted

• Hypovolemia (treatment)
• Hypoproteinemia (treatment)
• ------lt25 g/l, and edema
• Med J Aust 1992 157 340-3
• Hyperbilirubinemia, neonatal (treatment)
• Respiratory distress syndrome, adult (ARDS)
  (treatment adjunct)
• Cardiopulmonary bypass (treatment adjunct)

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Accepted

• Ascites (treatment adjunct)1
• Nephrotic syndrome, acute (treatment adjunct)
• .Hemodialysis--susceptible to shock and
  hypotension
• Pancreatitis (treatment adjunct)
  orIntra-abdominal infections (treatment adjunct)
• Liver failure, acute (treatment adjunct)

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Accepted

• Red blood cell resuspension
• Plasmapheresis

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Unaccepted

• Chronic cirrhosis or nephrosis
• Malnutrition
• Given in excessive amounts, albumin may increase
  the catabolism of endogenous albumin.
• DICP 1984 18
  202-12.
• Surg Gynecol Obstet 1986 163 359-62.

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Contraindication

• 1.allergy
• 2.heart failure
• 3.severe anemia

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BMJ 1998317235-240

• Human albumin administration in critically ill
  patients systematic review of randomised
  controlled trials

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• A systematic review of cohort studies meeting
  specified criteria estimated that for each 2.5
  g/l decrement in serum albumin concentration the
  risk of death increases by between 24 and 56.
• J Clin Epidemiol 199750693703.

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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).

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Result

• 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.

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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.

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A plausible mechanism

• Furthermore, albumin has been shown to distribute
  across the capillary membrane, a process that is
  accelerated in critically ill patients
• . It has been suggested that increased leakage of
  albumin into the extravascular spaces might
  reduce the oncotic pressure difference across the
  capillary wall, making oedema more likely.

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A plausible mechanism

• Is there by which human albumin might increase
  mortality?
• Albumin is used in hypovolaemia and
  hypoalbuminaemia because it is believed to be
  effective in replacing volume and supporting
  colloid oncotic pressure.
• However, albuminis also believed to have
  anticoagulant properties, inhibiting platelet
  aggregation and enhancing the inhibition of
• factor Xa by antithrombin III. Such anticoagulant
• activity might be detrimental in critically ill
  patients, particularly those with haemorrhagic
  hypovolaemia.