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Albumin - properties• Volume expansion 4% x 0.8, 5%, 20% x 3• Maintenance of colloid osmotic pressure (COP)
– Need a lot….no effect on other serum proteins..• Binding and transport - drugs (frusemide, antibiotics) toxins…..• Free radical scavenging• Immunological : stimulatory and inhibitory• Anticoagulatory effects and Procoagulatory effects :
– inhibit plat aggregation, inhibition of factor Xa by ATIII, TEG shows early hypocoagulable effects Tobias et al, Jorgensen et al
• Vascular permeability and over albuminisation Qiao et al
• What are we prescribing 5%, 20%, 25% +/- crystalloid• Aluminum toxicity, hypotension (vasoactive peptides)• Myocardial depression (animal work ; Ca binding)
HAS and HES increased No rolling and decreased adherence and aggregationAlbumin decreased activation of No and platelets Albumin and HES decrease E Selectin release
Alb and HES decrease to varying degrees decrease No : endothelial interactions
Albumin : Sepsis and thiol repletionQuinlan et al, Clinical Science 1998 95, 459
200 ml 20% albumin or placebo
• 37 ventilated acute lung injury • Total protein < 5 g/dl• 5 day protocol of 25 g of 25% HAS 8 hrly + frusemide or
placebo• Frusemide titrated to weight loss > 1kg/day• Total protein 1.9 vs 0.7 g/dl Albumin 1.5 vs 0.3 g/dl• Increased COP 8.3 vs 2.9 mmHg at study end• Weight loss 10 vs 4.7 Kg• Increased Na, HCO3 and decreased K• No change in creatinine
Albumin and frusemide in hypoalbuminaemia in ALI Martin G Crit Care Med 2002 ; 30:2175
Improved oxygenation : improved Pa02/Fi02 ratio by 40%
No difference in PEEP
No changes in SOFA scores, shock free days or rates ofre-intubation
No difference in % requiringmechanical ventilation
Albumin and diuretics and ascites
• 126 cirrhotics ascites• Diuretics vs Diuretics + Alb 12.5 g/day • Diuretics vs Diuretics + Alb 25g/week as
outpatient. Follow up over 3 yrs• Hospital stay shorter in Alb grp 20±1 vs 24±2 days
p<0.05• Risk of developing ascites lower in Alb grp
– 19%, 56%, 69% vs 30%, 74%, 79% (p<0.02)
• Survival similar in both groups Gentilini et al J Hepatol 30(4):639 1999
Terlipressin and albumin vs albuminMartin-Llahi M Gastroenterology 2008:134
• 1-2 mg 4hrly• Albumin daily 1g/kg• N=23 each grp• Improved renal function 43 vs 8%• No difference in 2 mnth survival • CVS complications
– 4 Alb vs 10 T + Alb
RCT Terlipressin in Type I HRSSanyal A Gatroenterology 2008 :134:1360
1 mg 6 hrly vs placebo
Albumin in both groups
If no response (30% decrease in creat) at day 4 : to 2mg 6 hrly
14 days Rx : 56 in each grp
Success defined as creatinine < 1.5 mg/dl for 48 hrs by Day 14
Rx success : 25 vs 12.5 %
Baseline to day 14
decrease in creatinine
0.7 vs 0 mg/dl
Similar survival between grps
HRS reversal
improved 180 day outcome
10 trials only type I and IIDrug ± alb vs no intervention
Vasoconstrictors + Alb : Effect on mortality at 15 days but not at 30, 90 or 180 days RR 0.6 (0.37-0.97)
Terlipressin + Albumin vs Albumin : decreased mortality in type IRR 0.83 (0.65-1.05)
• SBP frequently associated with renal failure• Associated with decreased effective blood volume and
high mortality• 126 patients iv cefotaxime or iv cefotaxime plus albumin
(1.5g/kg) at day 0 and day 3 (1.0 g/kg)• 94% and 98 % had resolution of infection• Renal failure in 21 (33%) cef grp vs
6 (10%) in alb/cef grp p=0.002
• Mortality 18 (29%) vs 6 (10%) • At 3 months the mortality was 41% vs 22% p=0.03
Albumin and renal impairment in patients with cirrhosis and SBP Sort P et al N Engl J Med 1999 5; 341 (6):403
HAS (4.5%) vs HES (6%,0.5) in paracetamol hepatotoxicity: prospective cohort study
Bernal W Lancet 2001
Albumin HES Number 51 51 Age 35 (20) 35 (22) Apache II 14 (17) 15 (16) INR 3.3 (2) 3.3 (2.6) Creatinine 124 (132) 142 (167) ARF o/a 14 (27%) 17 (33%)
Albumin HES Crystalloid (72 hrs) ml 6237 (6086) 6670 (6078) ml/kg 29 (42) 38 (52) Colloid (72 hrs) ml 2000 (2875) 3000 (2812) ml/kg 96 (104) 112 (92)
No differences in creatinine at any time point
RRT (n) 24 (47%) 25 (49%) Death / LT 19 (37%) 22 (44%) ICU stay 3 (6) 2 (11) No relationship between colloid used and ARF on multivariate analysis No difference if established ARF patients are excluded from study
20 patients with SBP : randomized within 12 hrs 1.5 g/kg at day 1 and 1.0 g/kg at day 3
20% albumin given over 6 hours 18 hrs HES 6% given over 18 hours
Well matched
Studied at resolution of SBP ( ascitic taps)
Recognize
Fluids and CVS status
Ventilatory issues
Drain ascites
Ileus : stop feeding
Ng drainage , flatus tubes
Open abdomen
Incidence 8 - 50%
• Ligand binder, extracellular metal ion-binding and radical-scavenging antioxidant.
• Baseline bloods• 200 ml 20% albumin or placebo• Alb 12.6 , 22.3 , 19 mg/ml at 0, 5min and 4 hrs • Thiol levels rose 138, 192 , 192 uM at 0, 5min and 4 hrs• Thiol levels remain elevated for 8 hrs - (33% of rise lost at 4
hrs)
Albumin : Sepsis and thiol repletionQuinlan et al, Clinical Science 1998 95, 459
Type Solvens Vol Exp
Hypo-oncotic Gelofusin NaCl 0.8
Albumin 4% NaCl 0.8
Iso-oncotic Albumin 5% NaCl 1
Hyper-oncotic HEA 6%-10% 200/0.5 NaCl 1.2
Voluven 6% 130/0.4 NaCl 1.2
Albumin 20% 3-4
Hyper-oncotic, hypertonic
HEA 6% 200/0.5 HS 7.2% 3
Dextran 70 6% HS 7.5% 3
Terlipressin ± albumin
Ortega et al Hepatology 2002;36:941• 0.5 mg 4 hrly , albumin 1g/kg/body weight day 1 then 20 -
40 g/day
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