A brief presentation about the current evidence based medical knowledge about the use of salt free albumin . After finishing this presentation you might discover that a lot of our practice lacks a solid basis regarding the use of this expensive drug.

1. Indications of salt free
albumin
By
Ahmed Adel Abdelhakeem
Assistant lecturer , Internal medicine department , GI
& Hepatology unit
Asyut university hospital

2. Human albumin (HA) is widely used for volume
replacement or correction of
hypoalbuminaemia.
The value of HA in the clinical setting continues
to be controversial, and it is unclear whether in
today's climate of cost consciousness, there is
still a place for such a highly priced substance.
It is therefore appropriate to update our
knowledge of the value of HA.

3. CLINICAL PHARMACOLOGY
The albumin concentration in plasma in healthy
humans ranges between 33 and 52 g litre.
Albumin is synthesized exclusively in the liver.
The normal rate of albumin synthesis is ∼ 0.2 g
kg body weight per day.

4. CLINICAL PHARMACOLOGY
Albumin is responsible for 70-80% of the colloid
pressure of normal plasma
carrier of hormones, enzymes, medicinal products
and toxins
The total body albumin in a 70 kg man is estimated
to be 350g, it has a half live of about 13-19 days
with a turnover of approximately 15g per day

5. FUNCTIONS OF ALBUMIN

6. INDICATIONS
Volume replacement in the perioperative period
Neither benefit nor harm was shown when using
HA to maintain hemodynamic stability in the
perioperative period when compared with
crystalloids or any other colloidal volume
substitute. (1)
If, in contrast, a newer synthetic colloid solution
was used (Mw 200 kDa, MS 0.5; eight trials
involving 299 patients) (2) , there was no longer
any statistically significant difference in
comparison with HA.

7. INDICATIONS
Volume replacement in intensive care unit patients
The largest trial currently available included ∼7000 patients and used a
prospective, randomized, double-blind design to compare volume
substitution in intensive care patients with either crystalloid
substitutes (saline solution) or HA 4% [Saline vs. Albumin Fluid
Evaluation (SAFE) study](3). No significant beneficial effect of HA
was found with respect to either morbidity and mortality or days
spent in the intensive care unit (ICU) or in hospital.
International guidelines for the management of severe sepsis and
septic shock (4) do not specifically recommend the use of HA for
volume replacement for hemodynamic stabilization in this setting.

8. INDICATIONS
Volume replacement in burn patients
Burns are seen as a potential indication for
administration of HA, but not in the first 24 h
after burn trauma. Crystalloid solutions are
preferred as volume replacement (5).

9. INDICATIONS
Volume replacement in trauma patients
The use of HA to correct hypovolaemia in trauma
patients has not been shown to have a significant
benefit in survival when compared
with other plasma substitutes. (6) (7)
in patients with traumatic brain injury, a post hoc
follow-up analysis of the data from the SAFE
study showed a significantly increased mortality
for the group treated with HA as opposed to the
non-albumin-treated group (8)

10. INDICATIONS
Volume replacement in hepatic surgery (including liver
transplantation)
Correction of hypovolaemia in patients undergoing major liver
surgery or liver transplantation has long been considered
an indication for using HA. However, such patients have
also successfully been treated with synthetic colloids. There
are no large-scale prospective trials (9). In a prospective
study of 40 patients after living related liver
transplantation, patients were randomized to an HA group
(n=20), where 20% HA was given to maintain serum
albumin level ≥3 g dl−1, and a control group (n=20), where
there was no correction for serum albumin (10).
Postoperative HA administration did not produce significant
clinical benefits in these patients.

11. INDICATIONS
Correction of hypoalbuminaemia in surgical or ICU
patients
reports confirmed that although hypoalbuminaemia is
associated with increased mortality, the use of albumin
in critically ill patients with a serum albumin
concentration ≤25 g litre is not associated with
reductions in mortality, duration of ICU stay or
mechanical ventilation, or in the use of renal
replacement therapy (11). Thus, there is limited
evidence to justify the use of (hyperoncotic) HA for
resuscitation or supplementation in these patients
(11).

12. INDICATIONS
Use of HA in undernutrition, malnutrition, and
enteropathies/malabsorption syndrome
No benefit for the administration of HA in
undernutrition, malnutrition, and enteropathies /
malabsorption syndrome has been shown.
Its composition of amino acids which has a low
ratio of some essential amino acids (tryptophan,
methionine, and isoleucine) makes HA unsuitable
for use in parenteral nutrition.

13. INDICATIONS
Correction of hypoalbuminaemia in patients with
liver cirrhosis
In cirrhotic patients with ascites, there is some
evidence that HA leads to a reduction in
morbidity and mortality (12) (13).
Three clinical situations have been described where
the use of HA may be indicated: spontaneous
bacterial peritonitis (SBP), hepatorenal syndrome
(HRS), and post-paracentesis syndrome (PPS).

14. INDICATIONS
Paracentesis in patients with liver cirrhosis
Paracentesis for drainage of ascites without
volume compensation is associated with the
risk of developing PPS. The incidence of PPS is
associated with a considerably higher risk of
developing renal failure and an overall
increased mortality (14) (15).

15. INDICATIONS
Correction of hypoalbuminaemia in Nephrotic
syndrome
In nephrotic syndrome, albumin is lost via the
kidneys. Compensation of the resulting
hypoalbuminaemia is not useful as most of it
is quickly eliminated again.

16. CONTRAINDICATIONS
Albumin should be used with caution in conditions where
hypervolemia and its consequences or hemodilution could
represent a special risk for the patient. Examples of such
conditions are:
established allergy against HA
Decompensated cardiac insufficiency
Hypertension
Esophageal varices
Pulmonary edema
Hemorrhagic diathesis
Severe anemia
Renal and post-renal anuria

17. CONCLUSION
the widespread use of HA worldwide appears to
be based on strong views rather than
controlled study results. The wider use of HA
should not be based on presumed potential
benefits in selected patient groups.

18. CONCLUSION
Systematic Reviews on albumin found that for patients
with hypovolaemia, there is no evidence that albumin
reduces mortality when compared with cheaper
alternatives (16).
These Reviews also showed that there is no evidence that
albumin reduces mortality in critically ill patients with
burns and hypoalbuminaemia.
A meta-analysis of randomized, controlled trials showed
that except in patients with ascites, the use of HA was
not associated with significantly improved morbidity
(17).

19. Effects of use of HA on risk ratio (RR) and confidence interval (CI)
for morbidity in different clinical settings

20. REFERENCES
1. Boldt J, Schöllhorn T, Mayer J, Piper S, Suttner S, The value of an albumin-based
intravascular volume replacement strategy in elderly patients undergoing major
abdominal surgery. Anesth Analg 2006;103:191-9
2. Wilkes MM, Navickis RJ, Sibbald WJ, Albumin versus hydroxyethyl starch in
cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding. Ann
Thorac Surg 2001;72:527-33.
3. Finfer S, Bellomo R, Boyce N, SAFE Study Investigators. A comparison of albumin
and saline for fluid resuscitation in the intensive care unit. N Engl J Med
2004;350:2247-56
4. Dellinger RP, Levy MM, Carlet JM, et al. ; International Surviving Sepsis Campaign.
International guidelines for management of severe sepsis and septic shock: 2008.
Crit Care Med 2008;36:296-327.
5. Boldt J, Pabsdorf M. Fluid management in burn patients: results from a European
survey—more questions than answers. Burns 2008;34:328-38.
6. Technology Assessment: Albumin, Non-protein Colloid, and Crystalloid Solutions.
Oak Book, IL, USA: University HealthSystem Consortium; 2000.
7. Wilkes MM, Navickis RJ. Patient survival after human albumin administration—a
meta-analysis of randomized controlled trials. Ann Intern Med 2001;135:149-64.

21. REFERENCES
8. Myburgh J, Cooper J, Finfer S, et al.; SAFE Study Investigators; Australian and New Zealand
Intensive Care Society Clinical Trials Group; Australian Red Cross Blood Service; George
Institute for International Health. Saline or albumin for fluid resuscitation in patients with
traumatic brain injury. N Engl J Med 2007;357:874-84.
9. Cammu G, Troisi R, Cuomo O, de Hemptinne B, Di Florio E, Mortier E. Anaesthetic
management and outcome in right-lobe living liver-donor surgery. Eur J Anaesthesiol
2002;19:93-8.
10. Mukhtar A, El Masry A, Moniem AA, Metini M, Fayez A, Khater YH. The impact of maintaining
normal serum albumin level following living related liver transplantation: does serum albumin
level affect the course? A pilot study. Transplant Proc 2007;39:3214-8.
11. Myburgh JA, Finfer S. Albumin is a blood product too—is it safe for all patients? Crit Care
Resusc 2009;11:67-70.
12. Gentilini P, Casini-Raggi V, Di Fiore G, et al. Albumin improves the response to diuretics in
patients with cirrhosis and ascites: results of a randomized, controlled trial. J Hepatol
1999;30:639-45.
13. Sort P, Navasa M, Arroyo V, et al. Effects of intravenous albumin on renal impairment and
mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med
1999;342:403-9.
14. Gines P, Tito L, Arroyo V, et al. Randomized comparative study of therapeutic paracentesis
with and without intravenous albumin in cirrhosis. Gastroenterology 1988;94:1493-502.

22. REFERENCES
15. Moore KP, Wong F, Gines P, et al. The management of ascites in cirrhosis:
report on the consensus conference of the International Ascites Club.
Hepatology 2003;38:258-66.
16. Alderson P, Bunn F, Li Wan Po A, et al. Human albumin solution for
resuscitation and volume expansion in critically ill patients. Cochrane
Database Syst Rev 2004;18:CD001208
17. Vincent JL, Navickis RJ, Wilkes MM. Morbidity in hospitalized patients
receiving human albumin: a meta-analysis of randomized, controlled
trials. Crit Care Med 2004;32:2029-38.

23. Thank you