ALBUMIN USE IN THE HEALTHCARE SETTING

An Evidence Advisory from Penn Medicine’s Center for Evidence-based Practice

December 2010

Project directors: ................. Prashant Mudireddy, MD and Ingi Lee, MD, MSCE
Internal review: .................... Kendal Williams, MD, MPH

Keywords: albumin

Summary
Indications for albumin use included in ≥ 3 guidelines:
• Large volume paracentesis (> 5L ascites fluid removed)
• For the treatment of Type I hepatorenal syndrome along with a vasoactive drug
• Spontaneous bacterial peritonitis if creatinine > 1mg/dl, BUN > 30mg/dl or total bilirubin >
4mg/dl
• Large therapeutic plasmapheresis (> 20mL/kg in single session or 20mg/kg/wk in successive
sessions)

Indications for albumin use included in ≥ 2 guidelines:

• Post-operative period to control ascites and peripheral edema after liver transplantation, if all
the following criteria are met: albumin < 2.5 mg/dL, pulmonary capillary pressure < 12mm of Hg,
Hct > 30%
• Nephrotic syndrome if albumin < 2 g/dL with hypovolemia and/or pulmonary and peripheral
edema exists
• Burns after initial 24 hours if > 30-50% body surface area involved
• Malnutrition in patients who cannot tolerate enteral nutrition and meet the following criteria:
diarrhea > 2 L/day, albumin < 2 g/dL, continuing diarrhea despite short chain peptides and
mineral formulas, no other cause to explain diarrhea

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No part of this publication may be reproduced without permission in writing from the
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Table of Contents
Introduction ..................................................................................................................................... 3
Methods........................................................................................................................................... 4
Protocol for Systematic Review.................................................................................................. 4
Literature search.......................................................................................................................... 4
Table 1. National Guideline Clearinghouse ........................................................................... 4
Table 2. Cochrane Library ..................................................................................................... 4
Table 3. Medline .................................................................................................................... 4
Table 4. EMBASE ................................................................................................................. 5
Table 5. Other resources (websites) ........................................................................................ 5
Results ............................................................................................................................................. 6
Table 6. Indications in Liver Disease .................................................................................... 6
Table 7. Indications in Critical Care ...................................................................................... 7
Table 8. Indications in Surgery .............................................................................................. 8
Table 9. Indications in Renal Disease .................................................................................... 9
Table 10. Indications for Burns ............................................................................................. 9
Table 11. Indications in Malnutrition .................................................................................. 10
Table 12. Other Indications.................................................................................................. 10
Table 13. Summary of Recommendations ........................................................................... 11
Appendix A – Abbreviations ........................................................................................................ 11
Appendix B – Grading System for Recommendations ................................................................. 13
References ..................................................................................................................................... 15

CEP Advisory: Indications for albumin use 2

Introduction
Human albumin is a physiologic plasma expander that has been used in the healthcare setting.
Its high cost and limited availability make it important to utilize albumin properly. We performed
an Evidence-based Advisory to identify appropriate indications for albumin use in the healthcare
setting from existing guidelines (which were based on systematic reviews and meta-analyses).

CEP Advisory: Indications for albumin use 3

Methods
Protocol for Systematic Review
Specific Aim
Summarize evidence on appropriate albumin use in the healthcare setting.

Methods
Study inclusion/exclusion criteria
Study designs considered: Guidelines
Patients: All hospitalized adult patients
Intervention: Albumin use
Other criteria: None
Data collection and synthesis
Databases searched: National Guideline Clearinghouse, Medline, Cochrane Library, EMBASE
Additional evidence sources (websites): American Association for the Study of Liver Disease
(AASLD), American College of Surgeons, American Gastroenterology Association,
American Society of Nephrology, American Thoracic Society (ATS), National Kidney
Foundation, Society of Critical Care Medicine, International Club of Ascites,
Study quality assessment: Not applicable
Data abstraction: By analyst
Data synthesis: Not applicable

Literature search

Table 1. National Guideline Clearinghouse

Srch Syntax Articles Retrieved Included
1 Albumin 93 2 1

Table 2. Cochrane Library

Srch Syntax Articles Retrieved Included
1 Albumin 220 12 0

Table 3. Medline
Srch Syntax Articles Retrieved Included
1 Exp Practice guidelines 14899 - -
2 exp Albumin/ad, ae, tu, th 11725 - -
3 1 and 2 8 - -
4 Limit 3 to (English language and humans) 6 6 6

CEP Advisory: Indications for albumin use 4

Table 4. EMBASE
Srch Syntax Articles Retrieved Included
Albumin/exp ([meta analysis]/lim OR [systematic review]/lim
1 244 32 2
AND [humans]/lim AND [English]/lim AND [embase]/lim

Table 5. Other resources (websites)

Srch Organization (URL) Results
1 American Association for the Study of Liver Disease (http://www.aasld.org) 1
2 American Gastroenterology Association 0
3 American College of Surgeons 0
4 American Society of Nephrology 0
5 American Thoracic Society (http://www.thoracic.org) 1
6 International Club of Ascites (http://www.icascites.org) 1
7 Society of Critical Care Medicine (http://www.sccm.org) 1
8 National Kidney Foundation 0

CEP Advisory: Indications for albumin use 5

Results
Table 6. Indications in Liver Disease
Author, Year Recommendations [Grade†]

AASLD, 2009(4) • Paracentesis: Albumin may not be necessary for a single paracentesis of < 4-5 L. [Class I, Level C]. For
large volume paracentesis (LVP), 6-8 g albumin/L of fluid removed can be considered. [Class IIa, Level C]
• Hepatorenal syndrome (HRS): Albumin infusion plus administration of vasoactive drugs such as
octreotide and midodrine should be considered in the treatment of Type I HRS. [Class IIa, Level B]
• Spontaneous bacterial peritonitis (SBP): Patients with ascitic fluid polymorphonuclear leukocytes (PMN)
counts ≥ 250 cells/mm3 (0.25x109/L) and clinical suspicion of SBP, who also have a serum creatinine > 1
mg/dL, blood urea nitrogen (BUN) > 30 mg/dL, or total bilirubin > 4 mg/dL should receive 1.5 g albumin/kg
body weight within 6 hours of detection and 1.0 g/kg on day 3. [Class IIA, Level B]
SIMTI, 2009(2) Appropriate indications for which there is widespread consensus
• Paracentesis: 5 g of albumin/L ascitic fluid removed after paracentesis of volumes > 5 L. [Grade 1C+]
• SBP: In association with antibiotics. [Grade 1C+]
Occasionally appropriate indications when other criteria are fulfilled
• Cirrhosis of the liver with refractory ascites: Generally ineffective except in patients with serum albumin <
2 g/dL. [Grade 2C]
• Acute liver failure: Contraindications to the use of non-protein colloids in acute liver failure. [Grade 2C]
• HRS: Albumin in association with vasoconstricting drugs. [Grade 2B]
Inappropriate indications
• Ascites responsive to diuretics
International Club of • HRS: Diagnosis of HRS includes meeting the following criteria: no improvement of serum creatinine
Ascites, 2007(7) (decrease ≤ 1.5 mg/dL) after at least 48 hrs of diuretic withdrawal and volume expansion with albumin
(recommended dose: 1 g/kg/day up to a maximum of 100 g of albumin/day). Vasoconstrictors and albumin
are recommended as the first line of treatment for type-1 HRS.
• SBP: Albumin infusion may prevent HRS in patients with SBP.
ATS, 2004(1) • Paracentesis: Hyperoncotic albumin should be administered in conjunction with LVP for diuretic-
refractory ascites. [Grade II-A]
• SBP: Albumin may be administered in conjunction with antimicrobial therapy. [Grade II-A]
University Hospital • Cirrhosis and paracentesis: Albumin, administered alone or in conjunction with diet modification and
Consortium, diuretics, should be avoided for the treatment of cirrhosis with ascites removal of < 4 L. Crystalloids should
1995(3) be considered the solution of choice to prevent complications associated with LVP; nonprotein colloids
and albumin should be considered second line agents for the prevention of complications following the
removal of ≥ 4 L of ascetic fluid.
Victorian Drug • Paracentesis: Albumin indicated in LVP (6-7 L removed in single paracentesis). The preferred solution is
Usage Advisory 20% normal serum albumin (NSA).
Committee, 1992(6)
†Appendix B
AASLD, American Association for Study of Liver Diseases; ATS, American Thoracic Society; HRS, hepatorenal syndrome; LVP,
large volume paracentesis; NSA, normal serum albumin; PMN, polymorphonuclear lymphocytes; SBP, spontaneous bacterial
peritonitis; SIMTI, Italian Society of Transfusion Medicine and Immunohaematology

CEP Advisory: Indications for albumin use 6

Table 7. Indications in Critical Care
Author, Year Recommendations [Grade†]

SIMTI, 2009(2) Occasionally appropriate indications when other criteria are fulfilled
• Hemorrhagic shock: Only if lack of response to crystalloids or contraindication to the use of non-protein
colloids. [Grade IA]
Inappropriate indications
• Non-hemorrhagic shock.
Surviving Sepsis • Sepsis: Fluid resuscitation may consist of natural or artificial colloids or crystalloids. There is no
Campaign, 2008(5) evidence-based support for one type of fluid over another. [Grade C] Fluid challenge in patients with
suspected hypovolemia (suspected inadequate arterial circulation) may be given at a rate of 500-1000 mL
of crystalloids or 300-500 mL of colloids over 30 min and repeated based on response (increase in blood
pressure and urine output) and tolerance (evidence of intravascular volume overload. [Grade E]
ATS, 2004(1) • Traumatic brain injury: Colloids should be avoided or used with caution. [Grade I]
• Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS): Fluid restriction is appropriate for
patients with hemodynamically stable ALI/ARDS [Grade II-A]; the combination of colloids and diuretics
may be considered in patients with hypo-oncotic ALI/ARDS. [Grade III]
University Hospital • Hemorrhagic shock: Crystalloids should be considered the initial resuscitation fluid. Colloids are
Consortium, appropriate for resuscitation in conjunction with crystalloids when blood products not immediately
1995(3) available. Nonprotein colloids are favored over albumin, except: if sodium restriction is required, the use of
25% albumin, diluted to 5% with 5% dextrose solution is recommended; and if nonprotein colloids are
contraindicated, use of 5% albumin solution is recommended
• Nonhemorrhagic (maldistributive) shock: Crystalloids are first line therapy. The effectiveness of colloid
solutions in the treatment of sepsis has not been demonstrated; however, in the presence of capillary leak
with pulmonary and/or peripheral edema, or following administration of 2+ L of crystalloid solution without
effect, nonprotein colloids may be used. If nonprotein colloids are contraindicated, albumin may be used.
Victorian Drug • Hypovolemia: Crystalloids or synthetic colloids are first choice. For hypoproteinemia, where the serum
Usage Advisory albumin < 25 g/L in the absence of edema, 20% normal serum albumin (NSA) is not indicated. For
Committee, 1992(6) hypoproteinemia where serum albumin < 25 g/L, in the presence of edema and/or clinically significant
hypernatremia, 20% NSA should be used as clinically appropriate. For extremely low hypoalbuminemia in
critically ill patients, 20% NSA may be used.
†Appendix B
ALI, acute lung injury; ARDS, acute respiratory distress syndrome; ATS, American Thoracic Society; NSA, normal serum
albumin; SIMTI, Italian Society of Transfusion Medicine and Immunohaematology

CEP Advisory: Indications for albumin use 7

Table 8. Indications in Surgery
Author, Year Recommendations [Grade†]

SIMTI, 2009(2) Occasionally appropriate indications when other criteria are fulfilled
• Heart surgery: Albumin is last-choice treatment after crystalloids and non-protein colloids. [Grade 2C+]
• Major surgery (>40% resection of the liver, extensive intestinal resection): Albumin should not be used in
the immediate post-operative period. Only indication is when serum albumin < 2 g/dL after normalization of
circulatory volume. [Grade 2C+]
• Liver transplantation: In the post-operative period to control ascites and peripheral edema, albumin can
be used to replace the loss of ascitic fluid from the drainage tubes, if albumin < 2.5 g/dL with a hematocrit
(Hct) > 30%. [Grade 1C]

Inappropriate indications
• Acute normovolemic hemodilution in surgery
University Hospital • Hepatic resection: Crystalloids to maintain effective circulating volume following major hepatic resection
Consortium, (>40%) is recommended. Nonprotein colloids and albumin are also appropriate depending on the function
1995(3) of the residual liver and hemodynamic status.
• Cardiac surgery: Crystalloids should be the fluid of choice as the priming solution for cardiopulmonary
bypass pumps. The use of nonprotein colloids in addition to crystalloids may be preferable in cases where
it is important to avoid pulmonary interstitial fluid accumulation. For postoperative volume expansion,
crystalloids should be considered first line, followed by nonprotein colloids, and finally albumin.
• Organ transplantation: Albumin and/or nonprotein colloid administration have not been demonstrated
conclusively to be effective during and/or after renal transplantation. Albumin may be useful for
postoperative liver transplant patients in the control of ascites and peripheral edema if the following are
met: serum albumin < 2.5 g/dL, pulmonary capillary wedge pressure < 12 mm Hg, and Hct > 30%. In these
cases, albumin may also be used to replace ascitic fluid lost through drainage catheters following liver
transplantation.
Victorian Drug • Cardiac surgery: Patients with adequate left ventricular function and short bypass times can tolerate
Usage Advisory crystalloid priming. For patients with poor left ventricular function or other complicating factors, such as
Committee, 1992(6) long bypass time, anemia or repeat surgery, a priming solution with higher amounts of colloids and /or
blood products is indicated. Albumin and synthetic colloids are essentially equivalent.
• Any surgery: For patients with postoperative hypovolemia requiring colloids, a synthetic colloid
considered solution of first choice.
†Appendix B
Hct, hematocrit; SIMTI, Italian Society of Transfusion Medicine and Immunohaematology

CEP Advisory: Indications for albumin use 8

Table 9. Indications in Renal Disease
Author, Year Recommendations [Grade†]

SIMTI, 2009(2) Appropriate indications for which there is widespread consensus

• Therapeutic plasmapheresis: Exchanges of > 20 mL/kg in one session or > 20 mL/kg/wk in more than
one session. [Grade 2C+]
Occasionally appropriate indications when other criteria are fulfilled
• Nephrotic syndrome: Only if serum albumin < 2 g/dL with hypovolemia and/or pulmonary edema.
[Grade 2C+]
• Contraindications to the use of non-protein colloids in moderate-severe renal failure (particularly when
anuria/oliguria); or dialysis treatment in the presence of severe abnormalities of hemostasis and
baseline albumin < 2-2.5 g/dL [Grade 2C]
Inappropriate indications
• Hemodialysis
ATS, 2004(1) • Dialysis-associated hypotension: Colloids are preferred in maintaining hemodynamics to achieve
dialysis goals. [Grade II-A]
University Hospital • Nephrotic syndrome: Short term albumin use along with diuretics is appropriate for patients with
Consortium, 1995(3) acute, severe peripheral and pulmonary edema.
• Plasmapheresis: Albumin with large volume plasma exchange is appropriate. Large volume plasma
exchange is defined as > 20 mL/kg in one session or > 20mL/kg/wk in repeated sessions. Crystalloid
solutions and albumin/crystalloid combinations should be considered cost-effective alternatives for small
volume exchanges.
Victorian Drug Usage • Plasma exchange: If available replacement with iso-osmotic albumin solution preferred. In certain
Advisory Committee, circumstances, particularly if plasma exchange is less frequent than once per week, less concentrated
1992(6) colloid or crystalloid solutions may be appropriate.
†AppendixB
ATS, American Thoracic Society; SIMTI, Italian Society of Transfusion Medicine and Immunohaematology

Table 10. Indications for Burns

Author, Year Recommendations [Grade†]

SIMTI, 2009 Occasionally appropriate indications when other criteria are fulfilled
• Burns: In the case of burns of > 30% body surface area (BSA) after the first 24 hrs [Grade 2C+]
University • Burns: Crystalloid solutions should be used for initial fluid resuscitation within the first 24 hrs. Colloids
Hospital should be administered with crystalloids if the following are true: burns cover > 50% BSA, at least 24 hrs
Consortium, have passed since the burn, and crystalloid therapy has failed to correct hypovolemia. Nonprotein colloids
1995(3) are recommended; if nonprotein colloids are contraindicated, albumin may be used.
†AppendixB
BSA, Body surface area; SIMTI, Italian Society of Transfusion Medicine and Immunohaematology

CEP Advisory: Indications for albumin use 9

Table 11. Indications in Malnutrition
Author, Year Recommendations [Grade†]

SIMTI, 2009(2) Occasionally appropriate indications when other criteria are fulfilled
• Malnutrition: Patients with diarrhea who cannot tolerate enteral nutrition in the following circumstances:
volume of diarrhea > 2L/day, serum albumin < 2 g/dL, continuing diarrhea despite short chain peptides and
mineral formulas, no other cause to explain the diarrhea. [Grade 2C]
University Hospital • Malnutrition: Albumin should not be used as a supplemental source of protein calories. However, patients
Consortium, not tolerating enteral feeds and meet all following conditions may benefit from albumin: diarrhea > 2 L/day,
1995(3) serum albumin < 2 g/dl, and continued diarrhea despite short chain peptides and elemental formulas, other
causes of diarrhea ruled out.
†Appendix B
SIMTI, Italian Society of Transfusion Medicine and Immunohaematology

Table 12. Other Indications

Author, Year Recommendations [Grade†]

SIMTI, 2009(2)
University Hospital
Consortium, 1995(3)
Victorian Drug Usage
Advisory Committee,
1992(6)
†AppendixB
NSA, normal serum albumin; SIMTI, Italian Society of Transfusion Medicine and Immunohaematology
Occasionally appropriate indications when other criteria are fulfilled
• Contraindications to the use of non-protein colloids in: pregnancy and breastfeeding; intracranial
hemorrhage; or hypersensitivity. [Grade 2C]
Inappropriate indications
• Albumin > 2.5 g/dL.
• Chronic hypoalbuminemia in the absence of edema and/or acute hypotension.
• Wound healing
• Protein-losing enteropathies and malabsorption
• Acute or chronic pancreatitis
• Cerebral ischemia
• Ovarian hyperstimulation syndrome
• Cerebral ischemia: colloid solutions (both nonprotein and albumin) should be discouraged in the
treatment of ischemic stroke or subarachnoid hemorrhage.
• Hypoalbuminemia: Albumin is not indicated if patient is otherwise stable. If the patient is critically
ill and/or actively bleeding, human albumin solution (20% NSA) may be indicated as dictated by
clinical circumstances.
• Protein losing enteropathies: Albumin not indicated is patient is otherwise stable. If patient has
low albumin, clinically unstable, or has other complications, may consider 20% NSA as clinically
indicated.
• Diuresis: Albumin not indicated for initiation of dieresis.

CEP Advisory: Indications for albumin use 10

Table 13. Summary of Recommendations
Victorian
International University Drug Usage
Surviving
Indications AASLD SIMTI Club of Hospital Advisory
Sepsis ATS
2009(4) 2009(2) Ascites Consortium Committee,
2008(5) 2004(1)
2006(7) 1995(3) 1992(6)
Indications in Liver Disease
LVP (>5L) X X X X
Diagnosis of HRS X
Treatment of Type
X X X
I HRS
SBP X X X X
Refractory ascites
with albumin < 2 X
g/dL
Indications in Critical Care
Hemorrhagic
shock
Septic shock
Indications in Surgery
Major surgery with
X
albumin < 2 g/dL†
Heart surgery X
Hepatic
insufficiency after
resection
Liver
transplantation
X X
with ascites and/or
edema
Indications in Renal Disease
Dialysis related
hypotension
Large volume
X X X
plasmapheresis
Nephrotic
syndrome with X X
edema
Indications in Burns
Significant burns
based on BSA X X
after 24 hrs
Cannot tolerate
enteral feeds with
X X
diarrhea, albumin
< 2 g/dL
Other Indications
Pregnant women
for volume
replacement
Hypovolemia after
ovarian
stimulation
AASLD, American Association for the Study of Liver Disease; ATS, American Thoracic Society; BSA, body surface area; HRS,
hepatorenal syndrome; LVP, large volume paracentesis; SIMTI, Italian Society of Transfusion Medicine and
Immunohaematology

CEP Advisory: Indications for albumin use 11

Appendix A – Abbreviations
AASLD American Association for the Study of Liver Disease
ATS American Thoracic Society
BSA Body surface area
BUN Blood urea nitrogen
Cr Creatinine
dL Deciliter
g Gram
Hct Hematocrit
HD Hemodialysis
Hg Mercury
Hr Hour
HRS Hepatorenal syndrome
kg Kilogram
L Liter
LVP Large volume paracentesis
mg Milligram
mm Millimeter
NA Not applicable
NSA Normal saline albumin
PMN Polymorphonuclear leukocytes
SBP Spontaneous bacterial peritonitis
SIMTI Italian Society of Transfusion Medicine and Immunohaematology
wk Week

CEP Advisory: Indications for albumin use 12

Appendix B – Grading System for Recommendations

AASLD (2009)(4)
Class I Conditions for which there is evidence and/or general agreement that a given
diagnostic evaluation, procedure, or treatment is beneficial, useful, and effective.
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion
about the usefulness/efficacy of a diagnostic evaluation, procedure, or treatment.
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well established by evidence/opinion.
Class III Conditions for which there is evidence and/or general agreement that a
diagnostic evaluation/procedure/treatment is not useful/effective and in some
cases may be harmful.

Level A Data derived from multiple randomized clinical trials or meta-analyses.

Level B Data derived from a single randomized trial, or nonrandomized studies.
Level C Only consensus opinion of experts, case studies, or standard-of-care.

SIMTI (2009)(2)
Grade 1 The authors are certain that the benefits are greater (or less) than the costs in
terms of risk and financial expenditure. This is therefore a strong
recommendation.
Grade 2 The authors are less certain concerning the above points and therefore make a
weaker recommendation.

Grade A A recommendation derived from the evidence of numerous, consistent

randomized studies.
Grade C+ A recommendation derived from the analysis of observational clinical studies, but
with very consistent results, or from results unequivocally extrapolated from
randomized studies.
Grade B The clinical studies providing the evidence were randomized, but had important
limitations (discordant results, methodological flaws).

International Club of Ascites (2007)(7)

NA

ATS (2004)(1)
Grade I Evidence obtained from at least one properly randomized, controlled trial.
Grade II-A Evidence obtained from well-designed controlled trials without randomization or
randomized trials without blinding.
Grade II-B Evidence obtained from well-designed cohort or case-control analytic studies,
preferably from more than one center or research group.
Grade II-C Evidence obtained from multiple time series with or without intervention,
uncontrolled cohort studies, and case series.
Grade III Opinions of respected authorities, based on clinical experience; descriptive
studies and case reports; or reports of expert committees.
NR Evidence not rated for clinically nonrelevant outcome.

CEP Advisory: Indications for albumin use 13

Surviving Sepsis Campaign (2004)(5)
A Supported by at least two level I investigations.
B Supported by one level I investigation.
C Supported by level II investigations only.
D Supported by at least one level III investigation.
E Supported by Level IV or V evidence.

I Large, randomized trials with clear-cut results; low risk of false-positive (alpha)
error of false-negative (beta) error.
II Small, randomized trials with uncertain results; moderate-to-high risk of false-
positive (alpha) and/or false-negative (beta) error.
III Nonrandomized, contemporaneous controls.
IV Nonrandomized, historical controls and expert opinion.
V Case series, uncontrolled studies, and expert opinion.

University Hospital Consortium (1995)(3)

NA

Victorian Drug Usage Advisory Committee (1992)(6)

NA

CEP Advisory: Indications for albumin use 14

References

1.Evidence-based colloid use in the critically ill: American thoracic society consensus statement.(2004).

American Journal of Respiratory and Critical Care Medicine, 170(11), 1247-1259.

2.Liumbruno GM. Bennardello F. Lattanzio A. Piccoli P. Rossettias G. Italian Society of Transfusion

Medicine and Immunohaematology (SIMTI). (2009). Recommendations for the use of albumin and

immunoglobulins. Blood Transfusion, 7(3), 216-234.

3.Vermeulen, L. C.,Jr, Ratko, T. A., Erstad, B. L., Brecher, M. E., & Matuszewski, K. A. (1995). A

paradigm for consensus. the university hospital consortium guidelines for the use of albumin, nonprotein

colloid, and crystalloid solutions. Archives of Internal Medicine, 155(4), 373-379.

4.Runyon,BA. Management of adult patients with ascites due to cirrhosis: An update(revised 2009 JUN).

American association for study of liver disease.

5.Dellinger,RP et al . Surviving Sepsis Campaign : International Guidelines for management of severe

sepsis and septic shock:2008

6. Human albumin solutions: Consensus statements for use in selected clinical situations: Subcommittee

of the Victorian drug usage advisory committee:1992

7. International club of Ascites guidelines : Criteria for diagnosis of hepatorenal syndrome.

CEP Advisory: Indications for albumin use 15