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Callum J, Skubas NJ, Bathla A, Keshavarz H, Clark EG, Rochwerg B, Fergusson D, Arbous S, Bauer SR, China L, Fung M, Jug R, Neill M, Paine C, Pavenski K, Shah PS, Robinson S, Shan H, Szczepiorkowski ZM, Thevenot T, Wu B, Stanworth S, Shehata N. Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. Chest 2024:S0012-3692(24)00285-X. [PMID: 38447639 DOI: 10.1016/j.chest.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis. METHODS Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology. The guidelines were revised after public consultation. RESULTS The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused. CONCLUSIONS Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.
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Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston.
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland
| | | | | | - Edward G Clark
- Division of Nephrology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa
| | - Sesmu Arbous
- Department of Critical Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland
| | - Louise China
- Department of Hepatology and ILDH, The Royal Free NHS Trust and University College London, London
| | - Mark Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT
| | - Rachel Jug
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cary Paine
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON
| | - Prakesh S Shah
- Institute of Health Policy, Management, and Evaluation, Mount Sinai Hospital, Toronto, ON; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON
| | - Susan Robinson
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London
| | - Hua Shan
- Department of Pathology, Stanford University School of Medicine, Palo Alto
| | | | - Thierry Thevenot
- Service d'Hépatologie, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France
| | - Bovey Wu
- Department of Internal Medicine, Graduate Medical Education, Loma Linda University, Loma Linda, CA
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford, England; Radcliffe Department of Medicine, University of Oxford, Oxford, England; John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Nadine Shehata
- Department of Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON; Transfusion Medicine Laboratory, Mount Sinai Hospital, Toronto, ON
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Hryciw N, Joannidis M, Hiremath S, Callum J, Clark EG. Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy. Clin J Am Soc Nephrol 2021; 16:820-828. [PMID: 33115729 PMCID: PMC8259476 DOI: 10.2215/cjn.09670620] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Among its many functions, owing to its oversized effect on colloid oncotic pressure, intravascular albumin helps preserve the effective circulatory volume. Hypoalbuminemia is common in hospitalized patients and is found especially frequently in patients who require KRT either for AKI or as maintenance hemodialysis. In such patients, hypoalbuminemia is strongly associated with morbidity, intradialytic hypotension, and mortality. Intravenous albumin may be administered in an effort to prevent or treat hypotension or to augment fluid removal, but this practice is controversial. Theoretically, intravenous albumin administration might prevent or treat hypotension by promoting plasma refilling in response to ultrafiltration. However, clinical trials have demonstrated that albumin administration is not nearly as effective a volume expander as might be assumed according to its oncotic properties. Although intravenous albumin is generally considered to be safe, it is also very expensive. In addition, there are potential risks to using it to prevent or treat intradialytic hypotension. Some recent studies have suggested that hyperoncotic albumin solutions may precipitate or worsen AKI in patients with sepsis or shock; however, the overall evidence supporting this effect is weak. In this review, we explore the theoretical benefits and risks of using intravenous albumin to mitigate intradialytic hypotension and/or enhance ultrafiltration and summarize the current evidence relating to this practice. This includes studies relevant to its use in patients on maintenance hemodialysis and critically ill patients with AKI who require KRT in the intensive care unit. Despite evidence of its frequent use and high costs, at present, there are minimal data that support the routine use of intravenous albumin during KRT. As such, adequately powered trials to evaluate the efficacy of intravenous albumin in this setting are clearly needed.
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Affiliation(s)
- Nicole Hryciw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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