Expert consensus on the use of human serum albumin in critically ill patients

Early high-volume resuscitation with crystalloid solution combined with albumin improves survival of critically ill patients: A retrospective analysis from MIMIC-IV database

BACKGROUND

Volume resuscitation is often required in critically ill patients. However, we have no clear consensus on the choice between crystalloid solution and colloidal solution. This study aimed to explore the effect of albumin administration in massive fluid resuscitation.

METHODS

This was a retrospective cohort study based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database (2008 and 2019). The prognosis of patients receiving albumin in combination with crystalloids and those receiving crystalloids alone was compared to assess the benefits of albumin in fluid resuscitation.

RESULTS

4426 patients received crystalloids alone (crystalloids group), 692 patients received albumin in combination with crystalloids within the first 24 h of initiation of crystalloids (early albumin combination group), and 382 patients received albumin after the first 24 h (late albumin combination group). Patients in early albumin combination group were more severe than those in Crystalloids group. Nevertheless, we found no statistically significant difference in mortality between the two groups. Multivariate logistic regression analysis using the propensity-score matched cohort showed that the 28-day and 60-day mortality in the early albumin combination group were lower than those in the crystalloids group (odds ratio: 0.64 [95% CI 0.50-0.82; P < 0.001] and 0.71 [95% CI 0.56-0.90; P = 0.004], respectively. Patients in early albumin combination group lived, on average, 1.16 days (95% CI 0.33-2.00; P < 0.01) and 3.3 days (95% CI 1.15-5.44; P < 0.01) longer than the crystalloids group during 28-day follow-up and 60-day follow-up.

CONCLUSION

Administration of albumin within 24 h after the initiation of crystalloids was associated with a lower mortality and a longer restricted mean survival time during 28-day follow-up and 60-day follow-up compared with crystalloid infusion alone. However, administration of albumin 24 h after the initiation of crystalloids was not associated with better prognosis compared to crystalloid infusion alone.

Albumin: a comprehensive review and practical guideline for clinical use

PURPOSE

Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration.

METHODS

Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication.

RESULTS

A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation.

CONCLUSION

Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.

Evaluating the predictive value of initial lactate/albumin ratios in determining prognosis of sepsis patients

Sepsis remains a significant clinical challenge owing to its complex pathophysiology and variable prognosis. The early identification of patients at a higher risk of poor outcomes can be crucial for improving treatment strategies. This study aimed to evaluate the predictive value of early serum lactate and albumin levels and the lactate/albumin (L/A) ratio for 28-day prognosis in patients with sepsis. Patients diagnosed with sepsis between January 2021 and December 2022 were evaluated using a retrospective cohort methodology. Inclusion followed the International Consensus on sepsis and septic shock (Sepsis-3) guidelines and patients were selected based on well-defined criteria. Variables such as lactate, albumin, and the L/A ratio were documented within the first 24 hours of admission. Statistical analyses were performed using various tools, including the nonparametric Mann-Whitney U test and receiver operating characteristic curves. A total of 301 patients were divided into the survival (n = 167) and death (n = 134) groups. Notable differences were detected in the incidence of pulmonary infection, shock, lactate, albumin, and the L/A ratio. The L/A ratio was identified as a key predictor with an area under the curve of 0.868, an optimal cutoff value of >0.17, a sensitivity of 56.21%, and a specificity of 94.18%. Significant disparities in mortality rates and survival times were observed for the lactate, albumin, and L/A levels. This study underscores the predictive value of early serum lactate and albumin levels and the L/A ratio for 28-day prognosis in patients with sepsis, with the L/A ratio showing a superior predictive capability. These findings highlight the importance of L/A ratio as a robust and precise marker for evaluating the future clinical course of patients with sepsis, potentially aiding early detection and management.

The efficacy of fat-free mass index and appendicular skeletal muscle mass index in cancer malnutrition: a propensity score match analysis

Background

Reduced muscle mass (RMM) is a phenotypic criterion for malnutrition; the appendicular skeletal muscle mass index (ASMI) and fat-free mass index (FFMI) are both applicable indicators in the global leadership initiative on malnutrition (GLIM) guideline. However, their sensitivity and prognostic effect remain unclear.

Methods

Clinical data of 2,477 patients with malignant tumors were collected. Multi-frequency bioelectrical impedance analysis was used to obtain ASMI and FFMI. RMM was confirmed by ASMI (< 7.0 kg/m² for men and < 5.7 kg/m² for women) or FFMI (< 17 kg/m² for men and < 15 kg/m² for women). Propensity score match analysis and logistic regression analysis were used to evaluate the efficacy of FFMI and ASMI in diagnosing severe malnutrition and multivariate Cox regression analysis to determine the efficacy of RMM in predicting survival.

Results

In total, 546 (22.0%) and 659 (26.6%) participants were diagnosed with RMM by ASMI (RMM.ASMI group) and FFMI (RMM.FFMI group); 375 cases overlapped. Body mass index (BMI), midarm circumference, triceps skinfold thickness, and maximum calf circumference were all significantly larger in the RMM.FFMI group for both sexes (P < 0.05). A 1:1 matched dataset constructed by propensity score match contained 810 cases. RMM.FFMI was an influential factor of severe malnutrition with HR = 3.033 (95% CI 2.068-4.449, P < 0.001), and RMM.ASMI was a predictive factor of overall survival (HR = 1.318, 95% CI 1.060-1.639, P = 0.013 in the RMM.ASMI subgroup, HR = 1.315, 95% CI 1.077-1.607, P = 0.007 in the RMM.FFMI subgroup).

Conclusion

In general, RMM indicates negative clinical outcomes; when defined by FFMI, it predicts nutritional status, and when defined by ASMI, it is related to poor survival in cancer patients.

Albumin infusion may decrease the mortality of hypoalbuminemia patients with severe acute pancreatitis: a retrospective cohort study

BACKGROUND

At present, the relationship between severe acute pancreatitis (SAP) and albumin infusion is not clear. We aimed to identify the impact of serum albumin on the prognosis of SAP and the association between albumin infusions and mortality for hypoalbuminemia patients.

METHODS

This was a retrospective cohort study that analyzed 1000 patients with SAP who were admitted to the First Affiliated Hospital of Nanchang University between January 2010 and December 2021 using data from a prospectively maintained database. Multivariate logistic regression analysis was conducted to reveal the relationship between serum albumin within 1 week after admission and poor prognosis of SAP. Propensity score matching (PSM) analysis was adopted to evaluate the effect of albumin infusion for hypoalbuminemia patients with SAP.

RESULTS

The prevalence of hypoalbuminemia (≤ 30 g/L) was 56.9% within 1 week after admission. Multivariate logistic regression identified that age (OR: 1.02; 95% CI: 1.00-1.04; P = 0.012), serum urea (OR: 1.08; 95% CI: 1.04-1.12; P < 0.001), serum calcium (OR: 0.27; 95% CI: 0.14-0.50; P < 0.001), lowest albumin level within 1 week after admission (OR: 0.93; 95% CI: 0.89-0.97; P = 0.002), and APACHE II score ≥ 15 (OR: 1.73; 95% CI: 1.19-2.51; P = 0.004) were independently associated with mortality. The PSM analysis demonstrated that mortality (OR: 0.52, 95% CI: 0.29-0.92, P = 0.023) was less common in albumin-infused than non-albumin-infused hypoalbuminemia patients. In subgroup analyses, doses > 100 g within 1 week after admission for hypoalbuminemia patients with albumin infusions was associated with lower mortality than doses ≤ 100 g (OR: 0.51, 95% CI: 0.28-0.90, P = 0.020).

CONCLUSIONS

Hypoalbuminemia in early-stage SAP is significantly related to poor prognosis. However, albumin infusions could significantly decrease mortality in hypoalbuminemia patients with SAP. Additionally, infusing sufficient albumin within a week after admission may decrease mortality in hypoalbuminemia patients.

Early human albumin administration is associated with reduced mortality in septic shock patients with acute respiratory distress syndrome: A retrospective study from the MIMIC-III database

Background: Sepsis-induced acute respiratory distress syndrome (ARDS) was associated with higher mortality. It is unclear whether albumin supplementation early in the course of ARDS can affect the prognostic outcomes of septic shock (SS) patients with ARDS. Methods: The MIMIC-III database was employed to identify SS patients with ARDS. The effect of early application (<24 h after ICU admission) of human albumin on 28-day mortality in SS patients with ARDS was explored. The propensity score matching was used to minimize the bias between the non-albumin and early albumin treatment groups. Results: The analysis for all eligible patients who received human albumin showed significantly lower 28-hospital mortality rates than the non-albumin group (37% versus 47%, p = 0.018). After propensity matching, the difference between the two groups also significantly (34.8% versus 48.1%, p = 0.031). Moreover, we found that the relationship between albumin use and reduced 28-day mortality was inconsistent across SOFA score subgroups (P_interaction = 0.004, non-adjustment for multiple testing). Conclusion: Early human albumin administration in SS patients with ARDS was independently associated with a reduction of 28-day mortality. Furthermore, the benefit of human albumin treatment appeared to be more pronounced in patients with a SOFA score of ≤ 10.

Moderator Effect of Hypoalbuminemia in Volume Resuscitation and Plasma Expansion with Intravenous Albumin Solution

Intravenous administration of crystalloid or colloid solutions is the most common intervention for correcting hypovolemia in intensive care unit patients. In critical illness, especially sepsis and severe trauma, vascular wall permeability increases, and trans-endothelial escape of serum albumin, the major oncotic plasma constituent, contributes to the development of hypoalbuminemia and edema formation. The volume effects of intravenous human albumin solution exceed those of crystalloid solutions. If hypoalbuminemia is an effect moderator, the crystalloid-to-albumin ratio of fluid resuscitation volumes is not well characterized. Randomized controlled trials have confirmed that intravenous administration of human albumin solutions for volume resuscitation results in a lower net fluid balance compared with crystalloids, and smaller infusion volumes may be sufficient for hemodynamic stabilization when human albumin solutions are used. This narrative review summarizes the current evidence and conclusions drawn regarding the role of hypoalbuminemia in volume resuscitation. In the 'Saline versus Albumin Fluid Evaluation' study using 4% human albumin solution or saline, the saline-to-albumin ratio of study fluids was significantly higher in patients with baseline serum albumin concentrations of 25 g/L or less as compared to patients with baseline serum albumin concentrations of more than 25 g/L. In patients receiving renal replacement therapy, intravenous administration of 20-25% human albumin solution reduces intradialytic hypotension and improves fluid removal better than saline if serum albumin levels are similarly reduced. These data suggest that hypoalbuminemia acts as an effect moderator in volume resuscitation and plasma expansion with albumin solution. The volume effectiveness of intravenous human albumin solution in resuscitation appears to be greater when the serum albumin levels are low. In clinical situations, serum albumin concentrations per se may inform when and how to include intravenous albumin in fluid resuscitation if large amounts of crystalloids are needed, which requires further studies.

A simple nomogram for predicting infectious diseases in adult kidney transplantation recipients

Objective

To investigate the risk factors of infectious diseases in adult kidney transplantation recipients and to establish a simple and novel nomogram to guide the prophylactic antimicrobial therapy.

Methods

Patients who received kidney transplantation between January 2018 and October 2021 were included in the study and were divided into a training and a testing set at a 1:1 ratio. Risk factors correlated to infectious diseases were selected using a Least Absolute Shrinkage and Selection Operator (LASSO) regression model. The prediction model was built by incorporating the variables selected by the LASSO model into a logistic regression equation. Calibration curves and receiver operating characteristic (ROC) curves were also applied to assess the model calibration and discrimination. A nomogram consisting of the selected factors was established to provide individualized risks of developing infections. Decision curve analysis (DCA) was adopted to estimate the net benefit and reduction in interventions for a range of clinically reasonable risk thresholds.

Results

In all, 863 adult kidney recipients were included in the study, and 407 (47.16%) of them developed infectious diseases during the 3-year follow-up period. A total of 8 variables were selected using LASSO regression and were retained for subsequent model construction and infection prediction. The area under the curve (AUC) was 0.83 and 0.81 in the training and testing sets, with high F scores of 0.76 and 0.77, sensitivity of 0.76 and 0.81, and specificity of 0.88 and 0.74, respectively. A novel nomogram was developed based on 8 selected predictors (requirement for albumin infusion, requirement for red blood cell infusion, triglyceride, uric acid, creatinine, globulin, neutrophil percentage, and white blood cells). The net benefit indicated that the nomogram would reduce unnecessary interventions at a wide range of threshold probabilities in both sets.

Conclusions

Adult kidney transplantation recipients are high-risk hosts for infectious diseases. The novel nomogram consisting of 8 factors reveals good predictive performance and may promote the reasonable antimicrobial prescription. More external validations are required to confirm its effectiveness for further clinical application.

Human albumin solution utilization patterns prior and during COVID-19 pandemic in United Arab Emirates: Time to develop and implement national guidelines on prescription and utilization

The human albumin solution (HAS) has limited but important indications in clinical practices. However, the inappropriate use of HAS can be costly. Thus, it is imperative to establish a practical protocol to use albumin products and rationalize its usage. The aim of this study was to identify HAS utilization patterns in a multi-specialty private hospital in Dubai, United Arab Emirates (UAE), before and during the COVID-19 pandemic. In addition, the objective was to demonstrate the importance of reconsidering the prescribing strategies for HAS administration. All data on 20% HAS administration in Mediclinic Welcare Hospital (MWEL) were retrieved between January 2019 and May 2021, including the total quantities administered and data on primary diagnosis. A total of 579 patient admissions with various diagnoses were included in this study. Our data suggested that the percentage of clinically indicated 20% HAS administrations decreased from 13.0% in the pre-COVID-19 phase to 1.5% in the COVID-19 phase (p<0.001). An increase in the administration of 20% HAS not backed by agreed clinical evidence followed the increase in new number of COVID-19 cases in the UAE. Our study suggests a large proportion of administered HAS, that drastically increased during COVID-19 with lack of evidence of its benefit. This study can be helpful to refine the institutional guidelines of HAS use, and frequent audits and interactive educational interventions are recommended to tackle this issue. In turn, the refinement of HAS administration guidelines could help to reduce the unjustified cost of inappropriate HAS use.