Nutrition in Clinical Practice

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Albumin Therapy in Clinical Practice

Christian M. Mendez, Craig J. McClain and Luis S. Marsano
Nutr Clin Pract 2005 20: 314
DOI: 10.1177/0115426505020003314
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Invited Review
Albumin Therapy in Clinical Practice
Christian M. Mendez, MD; Craig J. McClain, MD; and Luis S. Marsano, MD
Department of Internal Medicine, University of Louisville Medical Center, Louisville, Kentucky

ascites.1 The evidence to support albumin therapy in

these diverse conditions is quite variable and a focus
of this review. In this article, we will provide an
overview of albumin metabolism, use of albumin for
volume expansion, the potential therapeutic role of
albumin in liver disease, and the role of albumin
therapy in malnutrition.
Albumin is a protein of 584 amino acids. It is
highly soluble and has a strong negative charge.
Several variants in the amino acid sequence,
alloalbumins, coexist with normal albumin. Albumin makes up half the normal intravascular protein
mass and is responsible for 75% 80% of the plasma
colloid osmotic pressure.2
In a healthy person, 9 12 g of albumin are synthesized in the liver per day. The rate of synthesis is
controlled primarily by changes in the colloid
osmotic pressure and the osmolality of the extravascular space. Insulin, thyroxine, and cortisol also
stimulate the production of albumin; however,
growth hormone has no significant effect on albumin
synthesis. Importantly, in severe protein malnutrition, the production of albumin may be decreased.2,3
Albumin is a predominantly extravascular protein with a total extravascular mass of approximately 160 g, despite a lower interstitial concentration compared with serum concentration. The serum
concentration of albumin is about 4 g/dL in normal
individuals and the total intravascular mass is
about 120 g. Under normal circumstances, the albumin concentration in the interstitial space is half
that in the intravascular space. The half-life of
albumin is 1719 days.2
The catabolism of albumin takes place mainly in
the vascular endothelium at a rate of 9 12 g per day,
or 4% of total body albumin. The rate of albumin
degradation is related to its concentration. Calorie
and protein deprivation also accelerate albumin
catabolism. Serum levels of albumin may fall during
periods of stress, trauma, or sepsis despite its long
half-life. The drop may result from accelerated
redistribution from the intravascular space,
decreased synthesis, and increased catabolism.
Injury and infection result in a decrease of serum
albumin level of approximately 11.5 g/dL within
37 days.3 An example is the drop in albumin seen
in previously healthy patients who sustained head
injury and did not receive major fluid resuscitation
(Fig. 1). This rapid drop in the serum albumin

ABSTRACT: Albumin is the predominant product of

hepatic protein synthesis and one of the more abundant
plasma proteins. Among its multiple physiologic roles, it
plays an essential part in the generation of colloid-oncotic
pressure. In the United States, the indications for which
albumin therapy are considered include hypovolemia or
shock, burns, hypoalbuminemia, surgery or trauma, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, and sequestration of protein-rich
fluids. The use of this relatively expensive therapy
accounts for up to 30% of the total pharmacy budget in
certain hospitals. The use of albumin therapy in different
clinical situations and its influence in morbidity and
mortality have been reviewed in multiple randomized
controlled trials and meta-analyses. Despite frequent
reviews, the use of albumin remains controversial in
several clinical situations. At the same time, these valuable reviews seem to have documented the advantages of
albumin therapy in the management of ascites and clarified the use of albumin in volume resuscitation. More
studies have been recommended to investigate the use of
albumin in different doses and its role in hypoalbuminemia. This article will provide an overview of albumin
metabolism, use of albumin for volume expansion, the
potential therapeutic role of albumin in liver disease, and
the role of albumin therapy in nutrition.

Albumin infusions have been used for 50 years

in the management of a diverse range of medical and
surgical problems. Albumin infusions have multiple
effects including volume expansion, an increase in
colloid osmotic pressure, and hemodilution. This
form of therapy is used in multiple clinical settings
such as hypovolemia, shock, burns, surgery, trauma,
cardiopulmonary bypass, acute respiratory distress
syndrome, hemodialysis, acute liver failure, and

Correspondence: Christian M. Mendez, M.D., Department of

Internal Medicine, University of Louisville Medical Center, 550
S. Jackson St., ACB 3rd Floor, Louisville, KY 40292. Electronic
mail may be sent to cmmend01@gwise.louisville.edu.
0884-5336/05/2003-0314$03.00/0
Nutrition in Clinical Practice 20:314320, June 2005
Copyright 2005 American Society for Parenteral and Enteral Nutrition

314
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ALBUMIN THERAPY IN CLINICAL PRACTICE

Figure 1. Patients with severe head injury had a marked

increase in C-reactive protein () and a major decrease in
serum albumin (E) during their initial hospitalization.
Albumin gradually increased as patients clinically
improved at later timepoints. Reprinted from Boosalis
MG, Ott L, Levine AS, et al. Relationship of visceral
proteins to nutritional status in chronic and acute stress.
Crit Care Med. 1989;17(8):741747 with permission from
Lippincott Williams & Wilkins.

concentration is further highlighted by initial studies from our group demonstrating a decrease in the
serum albumin concentration following a single
injection of the pro-inflammatory cytokine, tumor
necrosis factor, into experimental animals (Fig. 2).
Under normal circumstances, albumin circulates
from the intravascular space across the capillary
wall into the interstitial compartment, and returns
to the intravascular space through the lymphatic
system. Albumin has a circulation half-life of
approximately 16 hours. The movement of albumin
across the capillary walls can be measured as the
transcapillary escape rate (TER), which is defined as
the percentage of intravascular albumin leaving the
intravascular compartment per hour. In healthy
volunteers, TER is around 4%5%. The TER is
determined by the capillary and interstitial free
albumin concentrations, the capillary permeability
to albumin, solvent and solute movements and, to a
lesser degree, the electrical charge across the capillary wall.3
Clearance of proteins from the interstitium is
dependent upon the lymphatic flow, which in
healthy individuals is around 120 mL/h, with a
protein content of about 80% of plasma. The flow of
lymph itself is dependent upon interstitial fluid
pressure, intrinsic pumping by the lymphatic vessels and external compression of vessels by muscle
contraction, arterial pulsation, and body movements.2,3
The distribution of exogenous albumin between
body compartments has been examined by the injec-

315

tion of radiolabeled albumin. Over the first 2 days,

there is a rapid phase of disappearance from the
plasma that correlates with the transcapillary
exchange rate or 4.5% per hour. The distribution
half-time is about 15 hours. Then there is a slower
decay of about 3.7% per day with an elimination half
time of about 19 days.4
The major physiologic functions of albumin
include:3
1. Binding and transport of molecules;
2. Colloid osmotic pressure effect;
3. Free radical scavenging;
4. Platelet function inhibition and antithrombotic
effects; and
5. Capillary membrane permeability.
Commercially available human albumin is
derived from pooled human plasma. Its use is not
without potential side effects. Complications associated with albumin administration include fluid overload, coagulation defects, hemolysis and myocardial
depression, perhaps related to the binding of calcium ions.35 Allergic reactions are rare but may
occur, usually to contaminants or to polymers that
form during processing. Viral transmission is highly

Figure 2. Effect of length of exposure to tumor necrosis

factor (TNF) on serum albumin concentration. Rabbits
were IV administered either saline or 1 of 2 TNF doses.
Blood was collected at 0, 8, 24, and 48 hours after
injection. Injection of the vehicle (control) caused no significant changes in serum albumin concentration. Injection of low-dose TNF caused a significant reduction in
albumin at 24 hours compared with all other time periods
(p .05). Injection of high-dose TNF caused significant
(p .05) hypoalbuminemia at 8, 24, and 48 hours compared with baseline. Furthermore, at 24 hours, high-dose
TNF administration caused a significant reduction in
albumin compared with low-dose TNF administration.
Values are mean SE, n 4. , control; , low-dose
TNF; f, high-dose TNF. Reprinted from Hennig B,
Honchel R, Goldblum SE, McClain CJ. Tumor necrosis
factor-mediated hypoalbuminemia in rabbits. J Nutr.
1988;118:1586 1590 with permission from the American
Society for Nutritional Sciences.

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MENDEZ ET AL

unlikely due to prolonged heat treatment during preparation. Complaints of nausea, fever, or chills usually
resolve with a reduction in the rate of transmission or
discontinuation of therapy. The risk of aluminum
toxicity may be increased by the use of albumin in
patients with renal failure. Exogenous albumin
administration may decrease endogenous synthesis
and increase the rate of albumin degradation.4

Use of Albumin in Volume Resuscitation

Colloids including albumin are widely used as
plasma substitutes for short-term replacement of
fluid volume. In the US, up to 26% of administered
albumin is for the treatment of acute hypovolemia
(eg, surgical blood loss, trauma, or hemorrhage).5
Successful volume resuscitation in the critically ill
patient and restoration of tissue perfusion is essential for patient survival. The optimal composition of
fluid for volume resuscitation in critically ill
patients has been the subject of controversy for
decades. Volume for volume, 4.5% albumin is
approximately 4 times as effective in expanding the
plasma volume as sodium-containing crystalloids.6
Isotonic crystalloid solutions (Ringers lactate,
normal saline) distribute within the extracellular
space, of which 25% is intravascular and 75% interstitial. The use of crystalloids minimizes the risk of
anaphylactic reactions and costs less than colloids.
Crystalloids can reduce colloid oncotic pressure and
may predispose to pulmonary edema. On the other
hand, colloidal solutions (albumin, starches, dextrans, gelatins, blood products, and substitutes) theoretically should remain primarily within the intravascular space and provide an oncotic gradient
favoring the entry of water from the interstitial
space.7 However, this does not seem to be the case in
septic shock due to damage of the vascular endothelium and transcapillary leak. Results from a small
study of fluid distribution in sepsis showed that 5%
albumin and 0.9% normal saline increased the interstitial fluid volume equally, and that albumin more
effectively increased the intravascular volume.7
In 1998, the Cochrane Injuries Group Albumin
Reviewers published a systematic review of randomized, controlled trials.8 Groups of critically ill
patients with hypovolemia, burns, or hypoalbuminemia who were given either albumin or plasma
protein fraction (PPF) were compared with control
groups who received either crystalloid solution or
nothing. The main objective of this review was to
quantify the effect of human albumin and PPF on
mortality in critically ill patients. Only randomized,
controlled trials comparing albumin/PPF with no
albumin/PPF or with a crystalloid solution in critically ill patients with hypovolemia, burns, or
hypoalbuminemia were selected. Thirty randomized
trials comprising 1419 patients and 156 deaths were
selected for analysis. For each patient category, the
risk of death in the albumin treated group was
higher than in the comparison group. In the sub-

Vol. 20, No. 3

group of hypovolemic patients, the relative risk of

death after albumin administration was 1.46 (95%
CI: 0.972.22). For the rest of subgroups including
burns and hypoalbuminemia, the relative risk of
death was also elevated. The pooled relative risk of
death with albumin administration was 1.68 (1.26
2.23). The pooled difference in the risk of death with
albumin was 6% (95% CI: 3%9%). When the analysis was repeated to include only the studies that
followed adequate allocation concealment (total of
13 trials), the relative risk of death was still higher
for each patient category with a pooled relative risk
of 1.61 (1.09 2.38).
In summary, no evidence that albumin reduces
mortality was found. In fact, there was a strong
suggestion that it may increase mortality in critically ill patients with hypovolemia, burns, or
hypoalbuminemia. The authors postulated that the
increased risk of death caused by albumin was
related to its anticoagulant properties, increased
interstitial oncotic pressure in patients with
increased capillary permeability, and the adverse
hemodynamic consequences or rapid volume
replacement. It was recommended that albumin
should not be used outside the context of a rigorously conducted randomized, controlled trial.
Several limitations of the Cochrane review were
outlined, including the lack of homogenous patient
population, the lack of consistency in disease severity and treatment regimens, the lack of correlation
between time of death and time of albumin administration, and the fact that mortality was not the
primary endpoint in many of the studies in the
review.9 Furthermore, in some of the studies, none
of the patients in the control group died, which is
highly improbable in a study conducted in an intensive care unit. Four of the studies in the review
included premature or newborn infants.
A recent update of the original meta-analysis by
the Cochrane Injuries Group Albumin Reviewers in
2002 included only 1 additional study with 100
additional patients.10 Not surprisingly, it reached
the same conclusion as the first review in 1998. For
each patient category, the risk of death was higher
in the albumin-treated group. The pooled relative
risk of death with albumin administration was 1.52
and the risk of death was increased by 5%.10
A meta-analysis by Wilkes and Navickis published in 2001 compared the use of albumin therapy
with crystalloid therapy, no albumin, or lower doses
of albumin.1 It included only randomized controlled
trials using purified albumin (the Cochrane review
included older studies using less pure preparations,
such as PPF, that are no longer in clinical use in
developed countries) and did not limit the analysis
to studies in critically ill patients.
Fifty-five trials involving surgery or trauma,
burns, hypoalbuminemia, high-risk neonates,
ascites, and other indications were included with a
total of 3504 patients, more than twice the number
included in the original Cochrane review. Several of

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ALBUMIN THERAPY IN CLINICAL PRACTICE

the studies reviewed in the hypovolemia group of the

Cochrane review were included in the surgery/
trauma group in the Wilkes meta-analysis.
Overall, this study detected no difference in mortality between patients treated with albumin and
patients treated with other fluids. For all trials, the
relative risk for death was 1.11 (95% CI: 0.951.28).
However, in the subgroups of trials that were judged
to be of higher quality (trials with blinding, mortality as an endpoint, no crossover, and 100 or more
patients), the relative risk of death was lower (0.73
1.04). In trials with 2 or more of these attributes, the
relative risk was further reduced. The contradiction
between these 2 large and conflicting reviews may
be a result of the difficulty in demonstrating a
benefit, lack of benefit, or influence on mortality of a
single therapeutic intervention in critically ill
patients.
In response to these conflicting results, the Australian and New Zealand Intensive Care Society, the
Institute for International Health of the University
of Sidney, and the Australian Red Cross Blood
Service designed a large double-blind, randomized,
controlled trial to compare the effects of fluid resuscitation with 4% albumin or saline on mortality in a
heterogeneous population of patients in the intensive care unit (ICU).11 Nearly 7000 patients underwent randomization and were followed for 28 days.
Patients with trauma, severe sepsis, or acute respiratory distress syndrome were included. Patients
admitted to the ICU after cardiac surgery, liver
transplantation, or after the treatment of burns
were excluded. Baseline characteristics of the
patients were similar as to age, gender, APACHE
score, physiologic variables, organ failure, mechanical ventilation requirement, and renal replacement
therapy. The trial showed no significant difference
between mortality at 28 days. In terms of morbidity,
length of stay in the intensive care unit, or length of
stay in the hospital, the difference between the 2
groups was not statistically significant. The frequency of need for mechanical ventilation, renal
replacement therapy, and the time until death were
also equivalent. In conclusion, the study provided
evidence that albumin and normal saline should be
considered clinically equivalent treatments for
intravascular volume resuscitation in critically ill
patients.
In terms of morbidity, a meta-analysis by Haynes
in 2003 included 79 randomized trials with a total of
4755 patients.12 The trials were divided into different subgroups including cardiac surgery, noncardiac
surgery, hypoalbuminemia, ascites, sepsis, burns,
and brain injury. There were a total of 48 trials in
the 2 surgical groups that compared the use of
albumin vs different crystalloids for volume expansion in order to attain certain hemodynamic endpoints. In cardiac surgery, albumin administration
resulted in lower fluid requirements, higher colloid
oncotic pressure, and reduced pulmonary edema.
The use of hydroxyethyl starch increased pulmonary

317

edema. In noncardiac surgery, fluid requirements

and pulmonary/intestinal edema were decreased
when albumin was given.
A recent meta-analysis by Vincent and coworkers
in 200413 looked at morbidity in hospitalized
patients receiving albumin compared with patients
receiving crystalloid, no albumin, or low-dose albumin. The analysis included 71 trials with 3782
patients divided into the categories of surgery or
trauma, burns, hypovolemia, high-risk neonates,
ascites, and other indications. There was only 1 trial
of hypovolemic shock (with 44 patients) that was
included in the other indications category. The
overall morbidity was significantly lower in albumin
recipients than in control patients with a relative
risk of 0.92. When looking at the surgery/trauma
group, no effect was demonstrable among these
trials.

Albumin Use in Chronic Liver Disease

Albumin infusions have been used in patients
with decompensated cirrhosis in 3 clinical situations: 1) to prevent circulatory dysfunction after
total paracentesis or serial large volume paracentesis;14 16 2) to decrease frequency of renal impairment and mortality in patients with spontaneous
bacterial peritonitis;17 and 3) as part of the treatment regimen for hepatorenal syndrome.18 20
The controversy regarding use of IV albumin is
more intense when it is used after paracentesis
because the preventable circulatory dysfunction is
transitory and mortality is not affected; in addition,
the cost of albumin is high ($525 per gram and its
supply is limited).21 After serial large volume paracentesis of 5 L each, a patient will receive 30 40 g of
albumin; after a total paracentesis (mean volume of
9 L), the patient will receive 54 72 g because albumin is usually given at a dose of 6 8 g per L of
ascitic fluid removed. When other volume expanders
were used (Dextran-70 and polygeline), they were
less effective than albumin.22 At this amount, the
use of IV albumin infusion remains questionable but
not unreasonable, considering that the alternative is
very close outpatient follow-up with serial laboratory tests, which is also expensive and often impractical or unrealistic. More recently, IV Terlipressin
infusion (1 g/bolus every 8 hours for a total of 3 g
over 16 hours) has been used in a randomized pilot
study, and was found to be as effective as IV albumin (at a dose of 8 g per L of ascites removed) in
preventing postparacentesis circulatory dysfunction. However, the mean volumes of paracentesis
were only 6 L and 4.9 L, respectively, and the cost of
both therapies was similar (994 vs 1,100).23 Terlipressin is not available in the United States.
The use of IV albumin in patients with spontaneous bacterial peritonitis (SBP) is less controversial,
but not free of controversy. In a prospective, ran-

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MENDEZ ET AL

domized study, 126 patients with SBP were

assigned treatment with cefotaxime alone (63
patients) or cefotaxime plus IV albumin at 1.5 g/kg
at time of diagnosis plus 1 g/kg on day 3 (total 175 g
albumin for a 70-kg person).17 Frequency of renal
impairment was reduced from 33% to 10%, the
in-hospital mortality rate from 29% to 10%, and the
3-month mortality rate from 41% to 22%, with the
addition of albumin. For each of these endpoints, the
difference was statistically significant with p .005.
The study has been criticized because the authors
did not (or failed to report that they did) volume
expand the control group with crystalloids. Because
it is not known if lesser volumes of albumin or if
other types of volume expansion (crystalloids, dextran, etc) can affect mortality in a similar way,
clinicians will have great difficulty in dismissing the
results of this study and are well justified in giving
albumin to these patients. New studies are needed
to determine if lower doses of albumin or alternative
volume expanders are equivalent.
The least controversial use of IV albumin is its
use as part of a regimen to reverse hepatorenal
syndrome (HRS). Hepatorenal syndrome has a very
high mortality with a 4-week survival of 20% and
10-week survival of 8%.24 There are 3 medical regimens that have proven to be life saving in patients
with HRS; all 3 of them use IV albumin to expand
the effective intravascular volume before giving a
second drug to increase vascular tone. The first
regimen gives IV albumin at a dose of 1 g/kg to
normalize plasma renin activity with repeated
infusions as needed, and then adds ornipressin 2
IU/h as a continuous infusion. Most patients had
reversal of HRS. Ornipressin is not available in the
United States.
The second regimen gave IV albumin infusion
until the central venous pressure reached 12 mmHg,
and then added oral midodrine and subcutaneous
octreotide, both given 3 times a day.19 Four-week
survival was improved to 80% and HRS was
reversed in all patients.
The third regimen gave IV albumin until the
central venous pressure was above 4 mmHg, repeating infusions to keep it at that level. Then, noradrenaline continuous infusion was started at 0.5 mg/h
with increments in dose by 0.5 mg/h every 4 hours
until the mean arterial pressure raised by 10 mmHg
above baseline and urine output exceeded 50 mL/h.
Only 1 of 12 patients failed to respond and the
2-month survival was 50% (vs the 15% expected
survival rate).20
Due to the clear impact in survival and the
relative noninvasiveness of these regimens, the use
of albumin is well justified in this setting. Indeed,
our management of renal dysfunction in liver disease has changed drastically over the past few years,
and mortality from hepatorenal syndrome has been
substantially improved.

Vol. 20, No. 3

Figure 3. Serial serum albumin (E) and prealbumin ()

levels compared with protein intake (). Although prealbumin levels better reflected protein intake, the delay
between increased protein consumption and the increase
in prealbumin levels was over a week. Thus the albumin
level reflected the clinical course of the patient, and
neither albumin nor prealbumin could be used as an
accurate marker of protein intake Reprinted from Boosalis
MG, Ott L, Levine AS, et al. Relationship of visceral
proteins to nutritional status in chronic and acute stress.
Crit Care Med. 1989;17(8):741747 with permission from
Lippincott Williams & Wilkins.

Albumin in Nutrition Support and

Hypoalbuminemia
Albumin concentrations can decrease rapidly over
a few hours secondary to increased loss of albumin
and altered distribution between the intra- and
extravascular compartments. Altered distribution
associated with increased capillary permeability is
probably the most frequent cause of hypoalbuminemia in critically ill patients. Decreased albumin
concentration secondary to decreased synthesis (eg,
severe liver failure) tends to occur over a period of
weeks to months.25 Because the serum level of
albumin is affected by many factors, serum albumin
correlates very poorly with the assessment of nutrition status26 28 (Fig. 3). As an indicator of morbidity
and mortality, serum albumin concentration is a
reliable tool.29 Hypoalbuminemia has been shown to
be associated with increased mortality and morbidity in hospitalized patients and community-dwelling
elderly persons.30 In elective surgery, an association
between hypoalbuminemia and adverse outcomes
has also been recognized for years. Results from the
large national Veterans Affairs surgical risk study
suggested that serum albumin concentration was a

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June 2005

ALBUMIN THERAPY IN CLINICAL PRACTICE

better predictor of surgical outcomes than many

other preoperative patient characteristics.29 This
large study included nearly 55,000 noncardiac surgical cases for which preoperative serum albumin
values were reported. Major surgeries included general, vascular, orthopedic, and thoracic. Compared
with other risk variables, serum albumin was the
strongest predictor of surgical outcomes with an
inverse relation between 30-day morbidity and mortality and preoperative serum albumin levels.
The provision of adequate nutrition support may
take weeks to months in order to raise the serum
albumin concentration. The administration of exogenous albumin as adjunctive therapy in hypoalbuminemic patients who are receiving parenteral
nutrition has been reviewed. Several randomized,
controlled trials evaluating the use of albumin in
hypoalbuminemic patients have been included and
reviewed repeatedly in several meta-analyses. The
1998 Cochrane Injuries Group Albumin Reviewers
reported a higher risk of death in patients receiving
albumin as adjunctive to parenteral nutrition with a
relative risk of 1.69.8 This subgroup included 9
trials, and 3 of them were performed in newborns.
The meta-analysis published by Wilkes in 20011
included only 5 randomized clinical trials in the
hypoalbuminemia subgroup with no pediatric trials.
Overall, no significant effect on mortality was
detected either across all trials combined or within
any of the 6 categories of clinical indications (surgery or trauma, burns, hypoalbuminemia, high-risk
neonates, ascites, and other).
In terms of morbidity, 3 large meta-analyses that
included the same randomized controlled trials concluded that there was a trend toward reduced morbidity by administering exogenous albumin in
hypoalbuminemic patients.31,32 Clinical benefit was
demonstrated when albumin levels 3 g/dL were
attained, thus showing a possible dose dependency.

Conclusions
Albumin use in critically ill patients has been the
topic of debate for many years and recent publications seem to have answered many questions about
indications of albumin therapy considered controversial in the past. The use of albumin infusions vs
crystalloids in fluid resuscitation has been the subject of several trials. Overall, no difference in survival has been detected.1,11 In terms of morbidity,
the role of albumin has not been shown to be
significantly better than the use of crystalloids.11,13
There seems to be enough evidence to consider
albumin and normal saline solutions as clinical
equivalents. The choice of one over the other seems
to be influenced by the clinicians preference, availability, and cost of the solution.
The use of albumin infusions in ascites seems to
be beneficial. The use of albumin infusions vs no
albumin in ascites was reviewed in the meta-analysis published by Vincent et al in 2004 and showed a

319

statistically significant benefit in terms of morbidity.13 The administration of albumin along with
antibiotic therapy is significantly better than antibiotic alone at preventing renal impairment and
reducing mortality in patients with cirrhosis and
spontaneous bacterial peritonitis.17 Such intervention is now standard of care in our institution. The
use of albumin vs other plasma expanders postparacentesis in cirrhotic patients with ascites is still not
clear and will be the subject of review by the
Cochrane Hepato-Biliary Group.33 This review will
assess the beneficial and harmful effects of albumin,
synthetic colloids, or IV infusion of ascitic fluid in
combination with paracentesis for the treatment of
ascites in cirrhotic patients.
The serum albumin level correlates with disease
severity and mortality in hospitalized patients.
However, there is no support for the use of albumin
as a nutrition support product. Further, the serum
albumin level unfortunately does not parallel protein or calorie administration with either parenteral
or enteral nutrition. Thus, the serum albumin level
should not be used as a marker of adequacy of
nutrition support. Finally, the use of exogenous
albumin in hypoalbuminemic patients may be beneficial and possibly dose-dependent. Further studies
are needed to delineate the role of albumin in
different doses in this particular setting.

Acknowledgments
This work was supported in part by the Department of Veterans Affairs. Dr McClain is supported
by the National Institutes of Health Grants
AA010762 and AA010496, and a Kentucky Science
and Engineering Foundation grant.

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