- Visit our website for more lectures: www.NephroTube.com - Subscribe to our YouTube channel: www.youtube.com/NephroTube - Join our facebook group: www.facebook.com/groups/NephroTube - Like our facebook page: www.facebook.com/NephroTube - Follow us on twitter: www.twitter.com/NephroTube

1. Albumin Use in
AKI, CKD & Dialysis
Why, When & How?
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
drgawad@gmail.com
Kasr Al Ainy – Kidney Week
19 May 2016

2. To get the presentation with full animations
please contact me on
drgawad@gmail.com
For more presentations visit
www.NephroTubeCNE.com

3. ALBUMIN
To use or not to use?

4. What is the Evidence?

5. Why Albumin?

6. Why Albumin?
Hemodynamic Stability

7. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

8. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

9. Albumin Use in:
• AKI in critically ill and septic patients.
With AKI or At risk of AKI
Albumin vs. Saline?

10. N Engl J Med 2004;350:2247-56.
n = 6997 Albumin Saline

11. N Engl J Med 2004;350:2247-56.
n = 6997 Albumin Saline

12. Outcome: Deaths
Cochrane Database Syst Rev. 2013 Feb 28;2:CD000567.

13. Crit Care Med. 2006 Dec;34(12):2891-7.
n = 691 Albumin Saline

14. Crit Care Med. 2006 Dec;34(12):2891-7.
n = 691 Albumin Saline

16. What is KDIGO missing?

17. N Engl J Med 2004;350:2247-56.
n = 6997

18. Crit Care Med. 2011 Feb;39(2):386-91
17 RCT, n=1977
Outcome: Deaths
p .047

19. Crit Care Med. 2013; 41: 580–637.

20. Crit Care Med. 2013; 41: 580–637.
And this is what KDIGO missing

21. What are KDIGO & Surviving Sepsis
Campaign missing?

22. BMJ. 2006 Nov 18;333(7577):1044.
n = 6045 Albumin Saline

23. J Chin Med Assoc. 2009 May;72(5):243-50

24. J Chin Med Assoc. 2009 May;72(5):243-50
Albumin ≤ 20 g/L Albumin > 20 g/L
A daily minimum of 25 g intravenous human albumin for
3 days during their first 7 days of admission

25. Crit Care Med. 2006 Oct;34(10):2536-40.
Albumin group:
300 mL of 20% albumin
solution on the first day,
then 200 mL/day provided
their serum albumin
concentration was <31 g/dL
Albumin ≤ 30 g/L
Control group:
No albumin

26. Crit Care Med. 2006 Oct;34(10):2536-40.
Albumin group:
300 mL of 20% albumin
solution on the first day,
then 200 mL/day provided
their serum albumin
concentration was <31 g/dL
Albumin ≤ 30 g/L
Control group:
No albumin

27. Crit Care Med. 2006 Oct;34(10):2536-40.
Albumin group:
300 mL of 20% albumin
solution on the first day,
then 200 mL/day provided
their serum albumin
concentration was <31 g/dL
Albumin ≤ 30 g/L
Control group:
No albumin
0
1
2
3
4
5
6
7
Albumin Control
Baseline SOFA Last SOFA
Delta SOFA
p Value: 0.03

28. Albumin use
AKI in critically ill and septic patients
• Isotonic crystalloids for initial management for
expansion of intravascular volume in patients at risk for
AKI or with AKI.
• Albumin in severe sepsis and septic shock when
patients require substantial amounts of crystalloids.
• Albumin as a part of initial volume replacement may
have a role in low serum albumin patient (<2-2.5 g/dl).

29. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

30. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

31. Albumin Use in HRS
• Prevention of HRS:
oParacentesis
oSBP
• Treatment of HRS:
o Type II HRS: Paracentesis
o Type I HRS: with Vasoconstrictors

32. Albumin Use in HRS
• Prevention of HRS:
oParacentesis
oSBP
• Treatment of HRS:
o Type II HRS: Paracentesis
o Type I HRS: with Vasoconstrictors

33. Paracentesis
- AASLD Practice Guidelines. Update 2012.
- Hepatology 2012;55:1172-1181.

34. Paracentesis
- AASLD Practice Guidelines. Update 2012.
- Hepatology 2012;55:1172-1181.

35. Paracentesis
- AASLD Practice Guidelines. Update 2012.
- Hepatology 2012;55:1172-1181.

36. Albumin Use in HRS
• Prevention of HRS:
oParacentesis
oSBP
• Treatment of HRS:
o Type II HRS: Paracentesis
o Type I HRS: with Vasoconstrictors

37. Spontaneous Bacterial Peritonitis
Cirrhotic patient + Ascites + deteriorating general
condition = SBP till proven otherwise
AASLD Practice Guidelines. Update 2012.

38. Clin Gastroenterol Hepatol. 2013 Feb;11(2):123-30.
4 RCTs (288 patients)

39. Clin Gastroenterol Hepatol. 2013 Feb;11(2):123-30.
4 RCTs (288 patients)

40. Albumin Use in HRS
• Prevention of HRS:
oParacentesis
oSBP
• Treatment of HRS:
o Type II HRS: Paracentesis
o Type I HRS: with Vasoconstrictors

41. Type I HRS: with Vasoconstrictors
EASL Clinical Practice Guidelines. 2010;53(May):397–417.
AASLD Practice Guidelines. Update 2012.
All patients should
receive ALBUMIN
1 g/kg up to 100 g
in the first day
20 to 40 g/day
afterward

42. `
Hepatology. 2010 Feb;51(2):576-84.
V.C. with albumin vs no intervention or albumin alone

43. `
Hepatology. 2010 Feb;51(2):576-84.
V.C. with albumin vs no intervention or albumin alone

44. BMC Gastroenterol. 2015 Nov 25;15:167
19 clinical studies with 574 total patients

45. Which type of albumin?
Salt-poor albumin !!
J Am Soc Nephrol. 2001;12(5):1010.
BMC Nephrol. 2012 Jan;13:92.

46. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

47. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

48. Mechanism of Development of
Refractory Edema
A
D DA Hypoalbuminemia
Decreased loop
diuretic secretion
M. Gawad. Urol Nephrol Open Access J 2014, 1(2)
M.Gawad. www.NephroTubeCNE.com

49. Mechanism of Development of
Refractory Edema
A
DA
Decreased loop
diuretic secretion
Hypoalbuminemia
D
M. Gawad. Urol Nephrol Open Access J 2014, 1(2)
M.Gawad. www.NephroTubeCNE.com

50. Mechanism of Development of
Refractory Edema
A DA
D
Increasedvenous
pressure
Decreased loop
diuretic secretion
Hypoalbuminemia
Increasedvenous
pressure
M. Gawad. Urol Nephrol Open Access J 2014, 1(2)
M.Gawad. www.NephroTubeCNE.com

51. Mechanism of Development of
Refractory Edema
A D A
D
Decreased loop
diuretic secretion
Hypoalbuminemia
M. Gawad. Urol Nephrol Open Access J 2014, 1(2)
M.Gawad. www.NephroTubeCNE.com

52. Cells. 2015 Oct 7;4(4):622-30

53. Cells. 2015 Oct 7;4(4):622-30
All subsequent RCTs have not addressed that
these patients are meeting the criteria of
diuretic resistance!!

54. Ann Pharmacother. 2003 May;37(5):695-700.

55. Ann Pharmacother. 2003 May;37(5):695-700.
Conflicting results

56. Journal of Critical Care 29 (2014) 253–259

57. Journal of Critical Care 29 (2014) 253–259

58. Journal of Critical Care 29 (2014) 253–259

59. Nephrotic Edema
Underfill vs. Overfill
Comprehensive clinical nephrology. 5th edition. 2015

60. Nephrotic Edema
Underfill vs. Overfill
Front Pediatr. 2016 Jan 11;3:111

61. Nephrotic Edema
Underfill vs. Overfill
Front Pediatr. 2016 Jan 11;3:111
Distinction between these mechanisms prior to
the initiation of diuretic therapy is not made in
routine clinical practice
Distinction has no effect on therapy strategy
selection in routine clinical practice

62. Albumin use
Diuretic Resistance - Hypoalbuminemia
Suggestion
Albumin should be reserved for patients with
resistant edema or ascites with sever
hypoalbuminemia (plasma albumin
<2.0 g/dL) whom diuretic doses have been
maximized with no response
Ann Pharmacother. 2003 May;37(5):695-700.
Individualization

63. Albumin use - Precautions
Administration of albumin prior to furosemide
could potentiate greater increases in diuresis (than
administering both at the same time)
Albumin exert maximal effect of intravascular
volume expansion within 30 to 60 min of
administration
Sci. 2001, 16, 448–454.

64. Albumin dose - Nephrotic syndrome
Manufacturers state to use 20g (100ml of 20%) once
daily in conjugation with diuretics 7–10 days
In one RCT it was used as Furosemide (40 mg) and
albumin (10 g of 20 % human albumin) was given
intravenously at time 24 hours
In another RCT it was used as 60 mg Furosemide
plus 200 ml of a 20% solution of albumin every 24
hours
Behring CSL. Albumin (Human) USP, 20% US Package Insert. 2012
BMC Nephrol. 2012 Jan;13:92.
Kidney Int. 1999 Feb;55(2):629–34.

65. Which type of albumin?
Salt-poor albumin !!
J Am Soc Nephrol. 2001;12(5):1010.
BMC Nephrol. 2012 Jan;13:92.

66. Albumin
vs. FFP
J NEPHROL 2006; 19: 621-627

67. FFP may be an economic substitute for
albumin !!
This needs to be tested more, but may be the
answer is Yes.
Albumin
vs. FFP
J NEPHROL 2006; 19: 621-627

68. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

69. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

70. Hemodialysis International 2006; 10:S10–S15
HypotensiveNot - Hypotensive

71. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD006758
Albumin vs. ???

72. J Am Soc Nephrol. 2004 Feb;15(2):487-92.

73. J Am Soc Nephrol. 2004 Feb;15(2):487-92.

74. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD006758
Given that no difference between albumin and normal saline in all
outcomes
(except for the amount of additional saline given, which was less in
the group treated with albumin).
Saline should be first-line therapy for treatment of IDH
in stable dialysis patients
Given the cost and relative rarity of albumin compared to saline.

75. Nephrol Dial Transplant. 2007 May;22 Suppl 2:ii22-44.

76. The best way is to
prevent recurrent
episodes of IDH
Curr Opin Nephrol Hypertens. 2012 Nov;21(6):593-9

77. J Nephrol 2011; 24(02): 208-217
Prospective crossover study
20 weeks
Routine infusion of 200 mL of colloids

78. J Nephrol 2011; 24(02): 208-217

79. J Nephrol 2011; 24(02): 208-217

80. J Nephrol 2011; 24(02): 208-217

81. J Nephrol 2011; 24(02): 208-217

82. J Nephrol 2011; 24(02): 208-217
Colloids were ineffective in some patients, suggesting
the need for careful and objective evaluation of these
expensive therapeutics on an individual level

83. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

84. Albumin Use in:
• AKI in critically ill and septic patients
• Hepatorenal syndrome
• Diuretic resistance – Hypoalbuminemia
• Intradialytic hypotension
• Therapeutic Plasma Exchange (TPE)

85. Albumin vs. FFP ??
Handbook of dialysis. Daugirdas, 5th edition, 2015

86. Albumin vs. FFP ??
Albumin is preferred as the
initial replacement solution
Handbook of dialysis. Daugirdas, 5th edition, 2015

87. Albumin for TPE
Albumin is preferred as the
initial replacement solution
• Replacement by albumin and crystalloid alone
may result in depletion of coagulation factors
→ increased risk of bleeding.
• FFP (1 or 2 units) at the end of therapy to
minimize the risk of bleeding.
Handbook of dialysis. Daugirdas, 5th edition, 2015

88. FFP for TPE
• TTP/HUS
• Preexisting defect in hemostasis and/or low
pretreatment serum fibrinogen level (<125
mg/dL)
• Patients at risk for bleeding; for example,
patients who are pre- or post surgery.
Handbook of dialysis. Daugirdas, 5th edition, 2015

89. Home Messages

90. Albumin use
AKI in critically ill and septic patients
• Isotonic crystalloids for initial management for expansion of
intravascular volume in patients at risk for AKI or with AKI.
• Albumin in severe sepsis and septic shock when patients
require substantial amounts of crystalloids.
• Albumin as a part of initial volume replacement may have a
role in low serum albumin patient (<2g/dl).

91. Albumin use
Hepatorenal Syndrome
Use of albumin in large volume
paracentesis, SPB, HRS
Decreases mortality
Improves renal function

92. Albumin use
Diuretic Resistance - Hypoalbuminemia
Albumin should be reserved for patients with
resistant edema or ascites with sever
hypoalbuminemia (plasma albumin
<2.0 g/dL) whom diuretic doses have been
maximized with no response
Ann Pharmacother. 2003 May;37(5):695-700.
Individualization

93. Albumin use
Intradialytic Hypotension
No role for albumin use

94. Albumin use
TPE
Albumin is preferred
FFP in some situations

95. ALBUMIN
To use or not to use?

96. Gawad
Thank You