done by: dr.fahad h. abduljabbar orthopaedic resident
TRANSCRIPT
Done by: Dr.Fahad H. AbduljabbarOrthopaedic Resident
Human plasma protein, 66 Kd 80% of plasma proteins Negatively charged Synthesized in the liver Degradation is poorly understood
Maintenance of the colloid osmotic pressure (COP)
Binding and transport, particularly of drugs Free radical scavenging Acid base balance Anti-coagulatory effects Affects vascular permeability
Frequency of hypoalbuminemiaFrequency of hypoalbuminemia
At the time of hospital admission, 20% of patients have hypoalbuminemia
Causes of hypoalbuminemiaCauses of hypoalbuminemia Decreased or abnormal synthesis synthesis. hepatitis, CLD, PEM,IBD Increased catabolism (major injuries,
malignancy,fever,pancreatitis) Increased loss: nephrotic syndrome,burns,gut
losses,hemorrhage & post surgical procedures Redistribution: Haemodilution (CHF,ARDS,
overhydration ) Increased capillary permeability (sepsis, SIRS
stress response)
Causes of hypoalbuminemiaCauses of hypoalbuminemia in in crtically ill patientscrtically ill patients Decreased hepatic production due to chronic
illness Redistribution into the extravascular space Dilution due to fluid administration
Morbidity & Morbidity & mortalitymortalityLow serum albumin levels are an important
predictor of morbidity and mortality. A meta-analysis of cohort studies found that, with every 10 g/L decrease in serum albumin, mortality was increased by 137% and morbidity increased by 89%
The study also showed increased in ICU stay by 28% & hospital stay by 71%
________________________________from Annals of Surgery
Posted 03/17/2003
Jean-Louis Vincent, MD, PhD, FCCM, Marc-Jacques Dubois, MD, Roberta J. Navickis, PhD, Mahlon M. Wilkes, PhD
Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium, and †Hygeia Associates, Grass Valley, California, U.S.A
Approach Approach for hypalbuminemiafor hypalbuminemiaHXGather past medical history for a history of
liver or renal failure, hypothyroidism, malignancy, and malabsorption.
Evaluate the patient for appropriate dietary intake.
Seek potential causes of acute or chronic inflammation that could explain the low albumin levels
ExaminationExamination Head, eyes, ears, nose, and throat Facial edema, macroglossia, parotid swelling,
conjunctival icterus, temporal wasting IntegumentaryLoss of subcutaneous fat, delayed wound
healing, dry coarse skin, painful dermatoses, peripheral edema, thin hair, spider angiomas, palmar erythema, jaundice
Cardiovascular - Bradycardia, hypotension, cardiomegaly
Respiratory: gynecomastia,signs of pleural effusion
GIT: ascitis, hepatosplenomegaly Musculoskeletal: wasting of mscles Neurological: asterixis, encephalopathy Genitourinary: testicualr atrophy
Lab studiesLab studiesMalnutrition: Lymphocyte count and BUN are decreased.
Transferrin, prealbumin, and retinol-binding protein have shorter half-lives compared with alubmin so it reflects short time change of PEM.
Inflammation: CRP & ESR are elevated. Nephrotic syndrome: The 24-hour urine collection contains
more than 3 g of protein in 24 hours. Cirrhosis: LFT (transaminase levels) may be elevated or normal
in patients who are cirrhotic. hepatitis screening, may be needed.
Malabsorption: Fecal fat studies including Sudan qualitative stain for fat, 72-hour quantitative fecal fat collection, and fecal a-1-antitrypsin clearance are needed.
Imaginig studiesImaginig studiesLiver USSmall bowel series for mucosal abnormalitiesCXR ? Chest infection ass. With pleural
effusionEchocardiography for CHF
Other dignostic proceduresOther dignostic proceduresLiver biopsyKidney biopsy
TreatmentTreatmentShould be focused on the underlying causeSimply replacing albumin intravenously has
generally been ineffective
Indications for albumin admin.Indications for albumin admin.Indicated Following large volume paracentesis Nephrotic syndrome resistant to potent diuretics Volume/Fluid replacement in plasmapheresis Serum albumin <2.0 g/dl Labile pulmonary, cardiovascular status Extensive burns ( >15%) Plasma exchange Intraoperative fluid requirement > 5-6 L in adults Premature infant undergoing major surgery
Possibly indicated Adult respiratory distress syndrome Ovarian hyperstimulation syndrome Cardiopulmonary bypass pump priming Fluid resuscitation in shock/sepsis/burns Neonatal kernicterus
Not indicated Correction of measured hypoalbuminemia or
hypoproteinemia Nutritional deficiency, total parenteral nutrition Pre-eclampsia Red blood cell suspension Simple volume expansion (surgery, burns) Wound healing
ContraindicatedContraindicatedpatients who are hypersensitive to albumin patients at special risk of developing
circulatory overload (CHF,renal insuffciency,chronic anemia)
Medical/Legal pitfallsMedical/Legal pitfalls
Administration of albumin, leading to lower serum ionized calcium levels and causing myocardial depression
Fluid overload Allergic reactions Misdiagnosis of ARDS secondary to
pulmonary edema
Literature reviewLiterature reviewNinety cohort studies fulfilling the inclusion
criteria were identified The total number of patients in the 90 studies
was 291,433 and the median number of patients per study was 281
Forty-nine of the studies, with 200,413 patients, representing 69% of the total patient population, were published since 1998
Cohort studiesCohort studiesThirty studies involved hospitalized patients
in general, 11 cardiac surgery, 12 noncardiac surgery, and 37 renal dysfunction.
. The median patient age across all included studies was 60 years (range 10-89)
Forty-one included studies were prospective and 45 were retrospective.
Four studies involved both prospective and retrospective components.
Five studies were multicenter investigations.
pooled OR for these trials was 2.37 (CI 2.10-2.68). Thus, the odds of death were increased by 137% with each 10-g/L decline in serum albumin, and the effect was statistically significant
Similarly, based on pooling within clinical indications, statistically significant increases in mortality odds of 102%, 116%, 180%, and 148% were observed for the hospitalization (OR 2.02; CI 1.52-2.70), cardiac surgery (OR 2.16; CI 1.47-3.16), noncardiac surgery (OR 2.80; CI 2.18-3.58), and renal dysfunction (OR 2.48; CI 2.11-2.91) categories, respectively.
Hypoalbuminemia was also an independent predictor of morbidity across all studies
The pooled OR for morbidity among all 18 studies assessing this endpoint was 1.89 (CI 1.59-2.24), indicating a statistically significant 89% increase in odds of complications corresponding to a 10-g/L reduction in serum albumin.
Significant increases in morbidity odds of 178%, 52%, 73%, and 102% were documented respectively among the subsets of studies involving hospitalization (OR 2.78; CI 1.30-5.98), cardiac surgery (OR 1.52; CI 1.12-2.04), noncardiac surgery (OR 1.73; CI 1.67-1.79), and renal dysfunction (OR 2.02; CI 1.48-2.74).
Length stayLength stayHypoalbuminemia was a significant independent
predictor of prolongation in both ICU and hospital stay. Length of ICU stay was a subject of three included studies.[60, 78, 84] The pooled OR for ICU stay was 1.28 (CI 1.16-1.40), indicating a significant 28% increase in odds for prolonged ICU stay per 10-g/L decrement in serum albumin.
OR and CI estimates for prolonged hospital stay were available from four included studies.[1, 39, 60, 78] The corresponding pooled OR was 1.71 (CI 1.33-2.21), revealing a significant hypoalbuminemia-related increase of 71% in odds of prolonged hospital stay.
Controlled TrialsNine prospective controlled trials with 535
total patients The median number of patients per trial was
38 (range 24-219). Seven of the trials were randomized.[111, 114-119]
Four trials involved pediatric patients.[111-113,
116] For the adult studies the median patient age was 59 years (range 47-71). The median duration of follow-up for both adult and pediatric trials was 26 days (range 5-150).
Pooled morbidity the pooled OR for occurrence of one or more
complications in individual patients was 0.74 (CI 0.36-1.49). Thus, morbidity was lower among albumin recipients, but the effect was not statistically significant. The pooled odds ratio was similar after exclusion of the two nonrandomized trials (OR 0.81; CI 0.41-1.60).[112, 113] There was no evidence of publication bias (P = .367). Among all control group patients, 48% (125/262) experienced one or more complications.
The effect of surgical procedures on serum albumin concentration.
Chirurgia (Bucur). 2008 Jan-Feb;103(1):39-43.Alberti LR, Petroianu A, Zac RI, Andrade JC Jr.
Alfa Institute of Gastroenterology of the Hospital of Clinics of the Federal University of Minas
Gerais, Brazil.PURPOSE: To assess the effect of surgical trauma on serum
albumin concentration during the immediate postoperative period
METHODS: 200 consecutive adult patients submitted to elective major surgeries (Group 1) and to medium size surgeries (Group 2) were identified according to gender, age and skin color.
Conclusion:There was a reduction in serum albumin in Group 1 (p < 0.0001) and Group 2 (p < 0.0001), with no difference between gender or skin colors for major surgeries. However, women showed a lower reduction than men in serum albumin in medium-sized surgeries. In medium-sized surgeries, black patients had the lowest reduction in albuminemia. The greater reduction in albuminemia occurred in patients older than 65 years old
Replacement of albumin after abdominal surgeryK Mahkovic Hergouth1 and L Kompan2
1Institute of Oncology, Ljubljana, Slovenia2Clinical Center, Ljubljana, Sloveniafrom 27th International Symposium on Intensive Care and Emergency Medicine
Brussels, Belgium. 27–30 March 2007Critical Care 2007, 11(Suppl 2):P405doi:10.1186/cc5565.
Method: retrospectively studied 76 successive patients operated on in the abdomen at the Oncologic Institute in Ljubljana in 1997/98 (group 1 – postoperative hypoalbuminemia treated with 20% albumin solution) and in 2000/01 (group 2 – no albumin treatment),
Conclusion: In both groups there was very significant drop of albumin concentration
in the first week after surgery . In group 2 albumin concentrations were very significantly lower than in group 1 until the fifth postoperative day
The difference diminished after the sixth postoperative day There was negative correlation between the postoperative albumin
concentration and the duration of surgery found no difference in the postoperative complication rate (surgical or
medical), length of stay and mortality between the groups.
AIDS Res Hum Retroviruses. 2007 Oct;23(10):1197-200. Links Graham SM, Baeten JM, Richardson BA, Wener MH, Lavreys L, Mandaliya K,
Ndinya-Achola JO, Overbaugh J, McClelland RS. Department of Medicine, University of Washington, Seattle, Washington 98104, USA.
A decrease in albumin of over 10% was associated with a 3.5-fold increase in the risk of progressing to a CD4 count <200
A greater decrease in albumin levels accompanying HIV-1 acquisition may be a marker for changes in early infection associated with more rapid disease progression.
Crit Care. 2005;9(6):649-50.
Is albumin administration in the acutely ill associated with increased mortality?
Vincent JL, Sakr Y, Reinhart K, Sprung CL, Gerlach H, Ranieri VM; 'Sepsis Occurrence in Acutely Ill Patients' Investigators.
Department of Intensive Care, Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium. [email protected]
METHODS: In a cohort, multicenter, observational study, all patients admitted to one of the participating ICUs between 1 May and 15 May 2002 were followed up until death, hospital discharge, or for 60 days. Patients were classified according to whether or not they received albumin
RESULTS: Of 3,147 admitted patients, 354 (11.2%) received
albumin and 2,793 (88.8%) did not. Patients who received albumin were more likely to have cancer or liver cirrhosis, to be surgical admissions, and to have sepsis. They had a longer length of ICU stay and a higher mortality rate, but were also more severely ill, as manifested by higher simplified acute physiology score (SAPS)
ICU and hospital mortality rates were higher in the patients who had received albumin than in those who had not (34.8 versus 20.9% and 41.3 versus 27.7%, respectively,
Conclusion:Albumin administration was associated
with decreased survival in this population of acutely ill patients. Further prospective randomized controlled trials are needed to examine the effects of albumin administration in sub-groups of acutely ill patients.
Cochrane Database Syst Rev. 2000;(2):CD001208. Links Cochrane Database Syst Rev. 2002;(1):CD001208.
Human albumin solution for resuscitation and volume expansion in critically ill patients.
Bunn F, Lefebvre C, Li Wan Po A, Li L, Roberts I, Schierhout G. Department of Epidemiology, Institute of Child Health, 30 Guilford Street, London, UK,
WC1N 1EH. [email protected]
Cohort study
CONCLUSIONS: There is no evidence that albumin administration
reduces the risk of death in critically ill patients with hypovolaemia, burns or hypoalbuminaemia, and a strong suggestion that it may increase the risk of death.
Take home messageTake home messageLow serum albumin is an independent indicator of
(poor) outcome in critical illness. There is no evidence that correcting
hypoalbuminemia improves outcome, indeed therapeutic albumin administration may worsen outcome.
Morbidity, mortality and length of stay were not influenced by albumin replacement.
The use of albumin in the critically ill patient is not supported by scientific evidence.
It is no more effective than other agents used in the treatment of hypovolaemia.
treatment of hypoalbuminaemia has no significant benefit. Efforts should be concentrated on correcting the underlying cause of disease to reverse hypoalbuminaemia.
The use of albumin may cause death.The use of albumin without an indication is a
waste for the resources
