This document discusses the role of albumin in critical care. It addresses several questions: 1) Albumin infusion should not target serum albumin levels. 2) Albumin is an effective volume expander, though less so than other colloids. 3) Albumin may help prevent acute kidney injury in hepatorenal syndrome but not in septic shock. 4) Albumin shows some benefits in sepsis like increased vasopressor-free days but results are borderline. 5) Albumin is not contraindicated in circulatory overload and may improve effects of diuretics. 6) Albumin benefits patients with liver cirrhosis for large volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome

1. ALBUMIN-THE COLLOID WHICH
REFUSES TO GO AWAY
Dr Tatikonda Chandra Mouli
MD (DNB) DM critical care

2. Greetings from Dept of critical care
IMS & SUM hospital , Bhubaneshwar

3. This is for two set of audience
Who thinks albumin is best
Who thinks albumin is worst

4. 1. Should albumin infusion target serum albumin levels ?
2. Albumin less effective as volume expander?
3. Role albumin in AKI
4. Use of Albumin in sepsis-A futile show ?
5. Is contraindicated in circulatory overload ?
6. Albumin and liver cirrhosis
7. Is Albumin harmful in TBI?
8. Paracentesis & Plasma exchange

6. Proportion of all Resuscitation episodes given in 2007 -2014 in 84 ICU’S
6S trial
Perner. NEJM 2012;367:124-34. doi: 10.1056/NEJMoa1204242

7. Human Albumin
• Edwin Joseph Cohen
• Albumin is only synthesised in liver (200 mg/kg/day)and is not stored in liver
• Half life is about 18-21 days
• Molecular weight of albumin is 66.5 KDa.
• NORMAL LEVEL OF ALBUMIN IN BODY IS 3.5 – 5.5 g/dl

9. ROLE OF ALBUMIN IN ICU
• Hypoalbuminemia
• Resuscitation fluid
• Replacement fluid for plasma exchange
• Sepsis and septic shock
• As an adjunct to Frusemide
• Liver Disease
 Hepatorenal syndrome
 Paracentesis
 spontaneous bacterial peritonitis with renal failure

10. Albumin in Resuscitation
•16 ICUs in Australia
•November 2001 – June 2003
•Comparing 4% albumin to 0.9% sodium
chloride.
•Excluded post-op cardiac surgery, liver
transplantation, burns
•6997 patients randomized

11. Most common terms used in ICU
Give some 100ml soda bicarbonate
Give some fluids
Thoda albumin dedo

12. Should albumin infusion target serum albumin
levels

13. ALBIOS Trial
•100 ICU in Italy
•August 2008 to February 2012
•severe sepsis
•1818 participants
•20% albumin solution with
crystalloid fluid compared to
crystalloid fluid alone
•Target Serum Albumin > 3g/L
•Excluded TBI patients

14. EARSS
• France 2011
• Septic shock patients with in 6hrs
• 20% albumin Vs 0.9% NS, 8th hourly for 3days
• 393 Vs 393 subjects
• No Mortality benefit (24.1% Vs 26.3%)

15. Albumin less effective as volume expander?
• Albumin 1:1.4 and colloids 1:1.2
• ALBIOS trial early vasopressor stoppage and Less Cumulative fluid requirement

16. Role albumin in preventing AKI ?
• Chronic Liver Disease to prevent HRS
Yes
• Septic shock  Albios Trial
 No
 No evidence of worsening renal parameters

17. Use of Albumin in sepsis-A futile show?
• Increases the plasma oncotic pressure
• Vasopressor free days (ALBIOS)
• SAFE – Mortality benefit in severe sepsis
With these borderline results still albumin
refuses to go away
Vincent et al. Critical Care 2014, 18:231

18. • 308 patients
• Cirrhotic with
sepsis-induced
hypotension
• 5% albumin Vs
0.9% saline

19. Is contraindicated in circulatory overload ?
1. Albumin improves the effects of diuretics (Albumin binds to diuretics)
Albumin + IV frusemide in hypoalbunemia with ALI
Martin et al Critical care medicine 2005,33 1681 to 1687
2. Albumin administration improves fluid
removal during RRT
Macerdo etal critical care 2021
3) Cirrhotic cardiomyopathy
Improves oxygenation
Increased negative balance
Albumin Vs Saline
Decrease hypotension 7% Vs 15%(p-
0.002)
Fluid removal 8.27 ml/kg/hr
Increased cardiac index by 10%
Umgelte et al,,
Germany

20. Albumin and liver cirrhosis
• LVP (large volume paracentesis)
>5lt  PICD
8gm/L- decreased shock, hyponatremia, AKI, encephalopathy and mortality
• SBP ( spontaneous bacterial peritonitis)
decreased Type-1 HRS by 60% and decreased mortality
• HRS-AKI (hepatorenal syndrome)
Metanalysis by 9 RCT, 1231 pts

22. Is Albumin harmful in TBI
• Recollect the SAFE trial
Albumin used was 4%
Any hypotonic solution cause inc
ICP

23. Is Albumin harmful in TBI
• Criticism lower osmolarity might contribute (Osm- 266-267 mosm/L)
• BASICS
• A 40yrs old male a known case of CLD with HE with ascites and coagulopathy
had motor vehicle accident admitted to ER with low GCS after resuscitation phase
he had shifted to MICU for further management ?
Albumin can be given to prevent HRS AKI
Can albumin given for Cirrhosis
What stopping you???

24. Is Albumin harmful in TBI
Hypo osmolar solutions worsens outcomes in TBI
May be harmful
Or
May not be

25. Albumin
• Antioxidant
• Controversies- excess albumin decreases effect of Tacrolimus  Graft rejection
• Newer Albumin Molecules Super Albumin
• Long-term Use of Albumin
Antibiotics and Albumin
(INCIFER Study)
• ANSWER study- positive trial
• MATCH study No benefit
• UK attire study

26. Albumin
• Albumin role in ACLD
(ASIA Trial  On going trial)
• Albumin Dialysis
• Plasmapheresis GBS, TTP
• MELD >30 improve outcomes
• AARC>11
Financial concerns
The COASST study-- Journal of
Critical Care (2007) 22, 197– 203

27. Story of albumin

28. "Science is built of facts as a house is built of bricks; but
an accumulation of facts is no more science than a pile of
bricks is a house“
Create your own reality

29. Unfathomed areas about Role of albumin
• Chronic kidney disease
• Hepatopulmonary syndrome
• Sarcopenia
• Procedures like TIPS
• Dose of albumin to be infused

30. Take Home
1. Should albumin infusion target serum albumin levels ?
NO
2. Albumin effective as volume expander?
Yes, but as compared to other colloids
3. Role albumin in preventing AKI ?
Yes HRS
4. Use of Albumin in sepsis-A futile show ?
Benefit in septic shock

31. Take Home
5. Is contraindicated in circulatory overload ?
No
6. Albumin and liver cirrhosis ?
Yes (specific to LVP,SBP,HRS)
7. Is Albumin harmful in TBI?
Needs further investigations
8. Paracentesis & Plasma exchange
Yes

32. Thank you