Impact of albumin infusion on prognosis of intensive care unit patients with congestive heart failure-hypoalbuminemia overlap: a retrospective cohort study

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.

Diuretic resistance and the role of albumin in congestive heart failure

Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.

Association of Hypoalbuminemia With Clinical Outcomes in Patients Admitted With Acute Heart Failure

Albumin is a protein produced by the liver essential for maintaining blood volume and regulating fluid balance. Hypoalbuminemia is characterized by low levels of albumin in the blood. It is also a marker of malnutrition-inflammatory syndrome. Several studies have demonstrated its prognostic role in patients with chronic heart failure; however, data regarding hypoalbuminemia in acute heart failure admissions are scarce. This study aims to analyze the relationship between hypoalbuminemia and heart failure. We used a retrospective cohort study surveying data from the 2016-2018 combined National Inpatient Sample (NIS) database. Adult hospitalizations for heart failure patients were identified using the ICD-10 codes, stratified into cohorts with and without hypoalbuminemia. Primary outcomes were (1) in-patient mortality, (2) length of stay, and total hospital charge. We also reclassified the HF admissions with hypoalbuminemia to those with systolic or diastolic heart failure to compare any differences in mortality and other in-patient complications. Multivariate linear and logistic regression were used to adjust for confounders and to analyze the outcomes. There were 1,365,529 adult hospitalizations for Congestive Heart Failure (CHF), and among them 1,205,990 (88 %) had secondary diagnoses of hypoalbuminemia. Patients with comorbid hypoalbuminemia were, on average, 8 years older (P < 0.001), predominantly white race, and males (P-value <0.001). HF hospitalizations with hypoalbuminemia had double in-hospital mortality than those without (4.8% vs 2.7%, P < 0.001). However, there was no difference in mortality between patients with Systolic heart failure and Diastolic heart failure with concomitant low albumin levels (from 4.9 % vs 4.7%, P 0.13). We found that patients admitted with HF and concomitant Hypoalbuminemia (HA) had nearly twice the odds of in-patient mortality than those with normal albumin levels. The Length of Stay (LOS) was higher between comparison groups. THC remained statistically indifferent in patients regardless of albumin levels but was greater in hypoalbuminemic patients with Systolic heart failure than Diastolic heart failure ones.

Association between albumin infusion and septic patients with coronary heart disease: A retrospective study based on medical information mart for intensive care III database

Coronary heart disease (CHD) is a common comorbidity in intensive care unit (ICU) patients, particularly in the elderly. This particular population may have worse conditions during sepsis, and it presents an overwhelming challenge for clinical practice. Previous studies suggested that patients with CHD have an increased risk of cardiovascular events, and low albumin concentration worsens the prognosis of patients with stable CHD. Hypoalbuminemia in patients with sepsis is common due to nutritional disorders, excessive consumption, and leakage. Albumin is a fluid often used for resuscitation in patients with sepsis. However, albumin infusion in patients with sepsis and CHD has rarely been studied. The effects and safety of albumin infusion in patients with sepsis and CHD remain unclear. Therefore, we collected medical information from Mimic-III (Mimic-III) and compared the all-cause mortality and cardiovascular mortality at 28- or 90-day between the albumin and non-albumin groups in septic patients with CHD. A total of 2,027 patients with sepsis and CHD were included in our study, with 405 in the albumin group and 1,622 in the non-albumin group. After propensity score matching (PSM), 350 pairs were included in our study. Improved survival benefits were found in the albumin group at the 28-day all-cause mortality compared with the non-albumin group (hazard ratio [HR], 0.54; 95% CI: 0.38–0.78; p = 0.0009). However, no difference was detected in the 90-day survival benefits (HR, 0.80, 95% CI: 0.60–1.06, p = 0.1207). Albumin infusion did not reverse cardiovascular mortality neither at 28th day nor at 90th day (cardiovascular mortality: 28 days, HR, 0.52, 95% CI: 0.23–1.19, p = 0.1218; 90 days, HR, 0.66, 95% CI: 0.33–1.33, p = 0.2420).