Review articleClinical indications for the albumin use: Still a controversial issue
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
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Clinical indications for HSA administration have emerged from evidence-based medicine.
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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.
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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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