Medication Summary

Hypoalbuminemia is a common phenomenon in patients with serious illness. Treatment should focus on the underlying cause rather than simply replacing albumin. Exogenous albumin is not used for the purpose of raising serum albumin levels.

Indications and the use of albumin administration in critically ill patients is an area of controversy; studies to clarify these issues are ongoing.^[3]Two major clinical trials compared albumin as a volume expander to crystalloids in the management of circulatory shock. Neither study specifically addressed the management of hypoalbuminemia. Both the SAFE^[4]and the ALBIOS study^[5]compared crystalloid to albumin infusions, and both documented a small but statically significant increase in serum albumin levels.

A separate question is whether or not albumin as a resuscitation fluid is useful as a volume expander or harmful for unrelated reasons. Although prior meta-analysis of small heterogeneous studies suggested that albumin infusions may be harmful as a volume expansion resuscitation fluid (increasing the mortality rate by 6% compared with crystalloid), the two large multicenter clinical trials (SAFE, ABLIOS) documented that, except in the SAFE trial, patients with neurotrauma had a worse outcome,^[4]whereas in the ABLIOS trial, patients with septic shock did better with albumin as a volume expander.^[5]In patients with neurotrauma, these trials found a small, but significant, increase in mortality compared with crystalloid therapy. However, neither trial was focused on treating hypoalbuminemia, but rather resuscitation from circulatory shock. In fact, outcomes are similar regardless of baseline serum albumin concentration; albumin administration for patients with hypoalbuminemia has no added benefit. Based on these studies of patients with septic shock, the benefit of colloid versus crystalloid administration for critically ill patients is not clearly demonstrated. Furthermore, the relative amount of albumin that can be effectively replenished by infusion is minimal, considering the normal albumin turnover rate.

These findings are in contrast to prior studies that also found no difference or increased mortality among those receiving albumin. Preliminary studies, including a favorable study by Dubois (2006), examined the effect of albumin on organ function in critically ill patients, but additional work is needed in this area.^[6]

For patients with hypoalbuminemia and critical illness, the administration of albumin has not been shown to reduce mortality.^[7]

Limited indications for albumin supplementation exist, and considerable clinical judgment is required when albumin is administered. Albumin has been used as one part of regimens designed to prevent hepatorenal syndrome in patients with cirrhosis in whom forced diuresis is being performed; however, this is controversial and survival benefit has not been clearly established. However, in general, albumin is not given specifically to treat hypoalbuminemia, which is a marker for serious disease.

Like crystalloids, colloids produce a dilutional effect on hemoglobin and clotting factors. Clinicians need to monitor the appropriate parameters to safeguard against iatrogenic complications.

Considering fluid resuscitation more generally, recent investigation found that 6% hydroxyethyl starch used for resuscitation in patients with severe sepsis was associated with a significant increase in acute renal failure, calling this approach into question.

The most effective method of minimizing hypoalbuminemia and restoring serum oncotic pressure is by creating a positive nitrogen balance. This is usually accomplished by enteral protein feeding and reversing the inflammatory state, if present. Clearly, those patients with nephrotic syndrome need the nephrosis treated as a primary problem. The importance of enteral nutrition as an early and continued treatment for hypoalbuminemia cannot be overemphasized.

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Author

Ruben Peralta, MD, FACS, FCCM, FCCP Deputy Trauma Medical Director, Professor and Director of Trauma, Emergency and Critical Care Fellowship Program, Senior Consultant in Surgery, Trauma, Emergency and Critical Care Medicine, Associate Director of Trauma Intensive Care Unit, Hamad General Hospital and Hamad Medical Corporation, Weill Cornell Medical College in Qatar

Ruben Peralta, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association of Blood Banks, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Brad A Rubery, MD Consulting Staff, Department of Internal Medicine, Division of Emergency Medicine, Gastroenterology Associates

Brad A Rubery, MD is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Thoracic Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Baxter Medical, Exostat, LiDCO<br/>Received honoraria from LiDCO Ltd for consulting; Received intellectual property rights from iNTELOMED.

Additional Contributors

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba Faculty of Medicine; Site Director, Respiratory Medicine, St Boniface General Hospital, Canada

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, World Medical Association

Disclosure: Nothing to disclose.

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