Clinical indications for the albumin use: Still a controversial issue

doi:10.1016/j.ejim.2013.05.015

European Journal of Internal Medicine

Volume 24, Issue 8, December 2013, Pages 721-728

https://doi.org/10.1016/j.ejim.2013.05.015 Get rights and content

Abstract

Human serum albumin (HSA) is the most abundant circulating protein and accounts for about 70% of the plasma colloid osmotic pressure. Beside the well known capacity to act as plasma-expander, HSA is provided of many other properties which are unrelated to the regulation of fluid compartmentalization, including binding and transport of many endogenous and exogenous substances, antioxidant function, immuno-modulation, anti-inflammatory activity, and endothelial stabilization.

Treatment (hepatorenal syndrome) or prevention (renal failure after spontaneous bacterial peritonitis and post-paracentesis circulatory dysfunction after large volume paracentesis) of severe clinical complications in patients with cirrhosis and fluid resuscitation in critically ill patients, when crystalloids and non-proteic colloids are not effective or contra-indicated, represents the major evidence-based clinical indications for HSA administration.

However, a large proportion of HSA prescription is inappropriate. Despite the existence of solid data against a real benefit, HSA is still given for nutritional interventions or for correcting hypoalbuminemia per se (without hypovolemia). Other clinical uses for HSA administration not supported by definitive scientific evidence are long-term treatment of ascites, nephrotic syndrome, pancreatitis, abdominal surgery, acute distress respiratory syndrome, cerebral ischemia, and enteric diseases.

HSA prescription should be not uncritically restricted. Enforcement of clinical practice recommendations has been shown to allow a more liberal use for indications supported by strong scientific data and to avoid the futile administration in settings where there is a lack of clinical evidence of efficacy. As a result, a more appropriate HSA use can be achieved maintaining the health care expenditure under control.

Introduction

Human serum albumin (HSA) is the most abundant circulating protein in the body provided of both oncotic and non-oncotic properties. Administration of exogenous HSA dates back in the World War II when it was used for fluid resuscitation. Since then, the use of HSA has been extended to many other diseases since physicians commonly believe in its efficacy. However, beside some clinical indications supported by solid scientific evidence, the administration in many other settings is still under debate or has been disproved by evidence-based medicine. As a result, clinical practical recommendations have been proposed to rationalize the prescription of HSA and avoid its futile use.

Section snippets

Structure

HSA is the main circulating protein in healthy individuals (3.5–5 g/dl), representing about 50% of the total protein content in the plasma. HSA is a small protein with a molecular weight of 66.5 kDa, consisting of a single chain of 585 amino acids organized in three repeated homologue domains (sites I, II, and III), each of which comprised of two separate sub-domains (A and B). In the human body, HSA assumes a globular heart-shaped conformation formed by α-helices for about 67%. Of the 35

The functions of albumin

Beside the well known oncotic function, HSA is provided of many other properties which are unrelated to the regulation of fluid compartmentalization, the so-called non-oncotic properties.

Clinical applications of albumin

HSA is largely used in clinical practice, but its administration is often inappropriate. Indeed, physicians commonly believe in its efficacy although many indications are still under debate or have been disproved by evidence-based medicine.

Hepatology is a setting where HSA is recommended by international guidelines, since randomized clinical trials and meta-analyses have demonstrated its efficacy to prevent or treat some severe complications of cirrhosis. In critically ill patients, HSA is also

Impact of clinical recommendations for albumin prescription

Beside the high proportion of inappropriate use, the elevated cost, the theoretical risk of disease transmission and the existence of more economical alternatives of comparable efficacy have prompted several clinical and economical evaluations aiming to rationalize and render more appropriate the use of HSA [69], [70], [71], [72], [73].

We recently reported the impact of internal practice guidelines for the appropriate use of albumin in the S. Orsola-Malpighi Academic Hospital in Bologna, Italy,

Learning points

•
Clinical indications for HSA administration have emerged from evidence-based medicine.
•
HSA is the first choice to expand effective volemia in patients with advanced cirrhosis and should be used to prevent renal failure after spontaneous bacterial peritonitis and the post-paracentesis circulatory dysfunction after large volume paracentesis or to diagnose and treat hepatorenal syndrome.
•
HSA is also the second-line treatment for fluid resuscitation in critically ill patients when crystalloids and

Conflict of interests

Paolo Caraceni has been a speaker for Grifols S.p.A.

Mauro Bernardi has been a speaker and consultant for Grifols Italia S.p.A, CLS Behring GNBH, PPTA Europe.

Marco Domenicali, Alessandra Tovoli, Lucia Napoli, Carmen Serena Ricci and Manuel Tufoni have no conflict of interest.

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The use of albumin is widespread and its use in many settings is still under debate. Frequently, inappropriate use is made in because of an analytical finding of hypoalbuminemia and / or in situations in which an attempt is made to correct a deficient nutritional status. In this study, the use of albumin in the hospitalized patient is analyzed, and evaluates the adequacy degree of its prescription to current recommendations.
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The use of albumin in our hospital has a wide margin of improvement, about 40% of the patients the prescriptions did not adjust to the recommendations of the clinical practice guidelines.

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Review articleClinical indications for the albumin use: Still a controversial issue

Abstract

Introduction

Section snippets

Structure

The functions of albumin

Clinical applications of albumin

Impact of clinical recommendations for albumin prescription

Learning points

Conflict of interests

Mol Aspects Med

Br J Anaesth

Am Heart J

Kidney Int

Biochim Biophys Acta

J Inorg Biochem

Am J Kidney Dis

J Hepatol

Gastroenterology

Gastroenterology

Gastroenterology

Hepatology

J Hepatol

Clin Gastroenterol Hepatol

Gastroenterology

Gastroenterology

Hepatology

J Hepatol

J Hepatol

J Hepatol

Crystal structure of human serum albumin at 2.5 A resolution

Protein Eng

The extraordinary ligand binding properties of human serum albumin

IUBMB Life

Review article: albumin as a drug–biological effects of albumin unrelated to oncotic pressure

Aliment Pharmacol Ther

Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications

Hepatology

Alterations in the functional capacity of albumin in patients with decompensated cirrhosis is associated with increased mortality

Hepatology

Physiological and pathological changes in the redox state of human serum albumin critically influence its binding properties

Br J Pharmacol

Glucose and free radicals impair the antioxidant properties of serum albumin

FASEB J

Impairment of the antioxidant properties of serum albumin in patients with diabetes: protective effects of metformin

Clin Sci (Lond)

Oxidation of albumin is enhanced in the presence of uremic toxins

Ren Fail

Human nonmercaptalbumin-2: a novel prognostic marker in chronic liver failure

Ther Apher Dial

Involvement of a lysine residue in the N-terminal Ni2 + and Cu2 + binding site of serum albumins. Comparison with Co2 +, Cd2 + and Al3 +

Eur J Biochem

NO forms an adduct with serum albumin that has endothelium-derived relaxing factor-like properties

J Clin Invest

Role of albumin and high-density lipoprotein as endotoxin-binding proteins in rats with acute and chronic alcohol loading

Alcohol Clin Exp Res

Effect of intravenous albumin on endotoxin removal, cytokines, and nitric oxide production in patients with cirrhosis and spontaneous bacterial peritonitis

Scand J Gastroenterol

Albumin and Ricinus communis agglutinin decrease endothelial permeability via interactions with matrix

Am J Physiol

Albumin and hydroxyethyl starch modulate oxidative inflammatory injury to vascular endothelium

Anesthesiology

Review article
Clinical indications for the albumin use: Still a controversial issue

Involvement of a lysine residue in the N-terminal Ni^2 + and Cu^2 + binding site of serum albumins. Comparison with Co^2 +, Cd^2 + and Al^3 +