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Vipler BS, Barelski AM, Vipler EE. Things We Do for No Reason™: Furosemide-albumin coadministration for diuretic resistance. J Hosp Med 2024. [PMID: 38372456 DOI: 10.1002/jhm.13297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/03/2023] [Accepted: 01/28/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Benjamin S Vipler
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adam M Barelski
- Division of Cardiovascular Diseases, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Erin E Vipler
- Division of Palliative Care, University of Colorado School of Medicine, Aurora, Colorado, USA
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Terradas Crespo E, Martin LG, Davidow EB. Retrospective evaluation of indications, transfusion protocols, and acute transfusion reactions associated with the administration of lyophilized canine albumin: 53 cases (2009-2020). J Vet Emerg Crit Care (San Antonio) 2023; 33:567-576. [PMID: 37528743 DOI: 10.1111/vec.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 08/03/2023]
Abstract
OBJECTIVES To describe the administration of lyophilized canine albumin (LCA) and determine the increase in serum albumin concentrations post-LCA transfusion. To describe the incidence and types of acute transfusion reactions (TRs) and associated outcome in dogs presenting to a veterinary teaching hospital. DESIGN Retrospective and descriptive study from 2009 to 2020. SETTING University teaching hospital. ANIMALS Fifty-three client-owned dogs included in the study if they received an LCA transfusion and had vital sign monitoring recorded for at least for 4 hours after starting the LCA transfusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 53 dogs available for study inclusion received 64 LCA transfusions. Signalment; underlying disease; indications for LCA transfusion; pre- and posttransfusion serum albumin concentration; volume, concentration, and dose of LCA; duration of transfusion; administration of other blood products or synthetic colloids; occurrence, timing, and type of TR; length of hospitalization; and outcome were recorded. Serum albumin concentrations increased post-LCA transfusion, with a median dose of 0.56 g/kg and a median posttransfusion serum albumin increase of 3 g/L (0.3 g/dL) (P = 0.008). TRs occurred in 13 of 64 (20.3%) transfusion events. Volume per kilogram, dose (g/kg), concentration, duration of transfusion, and additional administration of synthetic colloids were not associated with TRs. Three (23%) TRs were classified as febrile nonhemolytic transfusion reaction, 5 (38.5%) as transfusion-associated dyspnea (development of respiratory distress and limited diagnostics), and 5 (38.5%) had clinical signs that could not be defined by any 1 TR category. Six (46.1%) of 13 events were nonsevere, 5 (38.5%) were severe, and 2 (15.4%) were life-threatening. CONCLUSIONS Administration of LCA can be used to increase serum albumin concentrations, although the clinical implications of this increase are unknown. Acute TRs associated with LCA are relatively frequent and can be life-threatening. Careful monitoring is vital.
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Affiliation(s)
- Emilia Terradas Crespo
- Department of Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
| | - Linda G Martin
- Department of Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
| | - Elizabeth B Davidow
- Department of Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
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Erstad BL. Why Do the Mechanistic Actions of Albumin Not Translate Into Tangible Clinical Benefits? Ann Pharmacother 2022; 57:746-750. [PMID: 36189638 DOI: 10.1177/10600280221126629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Albumin has only reduced crude mortality in one randomized controlled trial conducted to date. This raises the question as to why potentially beneficial oncotic and pleiotropic properties of albumin do not consistently translate into clinically important outcomes. Four postulated explanations are provided as to why the theoretical advantages of albumin are not apparent in clinical trials: diminished oncotic action due to leakage of albumin from the intravascular compartment, modification of the pleiotropic properties of albumin both in vitro and in vivo, the ability of other plasma proteins to take over the major functions of albumin, and possible adverse effects.
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Affiliation(s)
- Brian L. Erstad
- Department of Pharmacy Practice & Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
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Jagdish RK, Maras JS, Sarin SK. Albumin in Advanced Liver Diseases: The Good and Bad of a Drug! Hepatology 2021; 74:2848-2862. [PMID: 33772846 DOI: 10.1002/hep.31836] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 02/13/2021] [Accepted: 03/17/2021] [Indexed: 12/13/2022]
Abstract
Human serum albumin is the most abundant plasma protein, and it regulates diverse body functions. In patients with advanced and decompensated cirrhosis, serum albumin levels are low because of a reduction in the hepatocyte mass due to disease per se and multiple therapeutic interventions. Because of their oncotic and nononcotic properties, administration of human albumin solutions (HAS) have been found to be beneficial in patients undergoing large-volume paracentesis or who have hepatorenal syndrome or spontaneous bacterial peritonitis. Albumin also improves the functionality of the immune cells and mitigates the severity and risk of infections in advanced cirrhosis. Its long-term administration can modify the course of decompensated cirrhosis patients by reducing the onset of new complications, improving the quality of life, and probably providing survival benefits. There is, however, a need to rationalize the dose, duration, and frequency of albumin therapy in different liver diseases and stages of cirrhosis. In patients with acute-on-chronic liver failure, potentially toxic oxidized isoforms of albumin increase substantially, especially human nonmercaptalbumin and 2, and nitrosoalbumin. The role of administration of HAS in such patients is unclear. Determining whether removal of the pathological and dysfunctional albumin forms in these patients by "albumin dialysis" is helpful, requires additional studies. Use of albumin is not without adverse events. These mainly include allergic and transfusion reactions, volume overload, antibody formation and coagulation derangements. Considering their cost, limited availability, need for a health care setting for their administration, and potential adverse effects, judicious use of HAS in liver diseases is advocated. There is a need for new albumin molecules and economic alternatives in hepatologic practice.
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Affiliation(s)
- Rakesh Kumar Jagdish
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaswinder Singh Maras
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
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Efficacy of furosemide-albumin compared with furosemide in critically ill hypoalbuminemia patients admitted to intensive care unit: a prospective randomized clinical trial. ACTA ACUST UNITED AC 2020; 28:263-269. [PMID: 32291620 DOI: 10.1007/s40199-020-00339-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Some physicians co-administer albumin with loop diuretics to overcome diuretic resistance in critically ill hypoalbuminemia patients, though previous studies have reported conflicting results on this matter. OBJECTIVE The effects of adding albumin to furosemide to enhance its efficacy in critically ill hypoalbuminemia patients are evaluated. METHODS This was a non-blinded randomized trial. 49 adult critically ill patients with hypoalbuminemia and generalized edema who received randomly furosemide and furosemide/albumin complex were enrolled. The patients' urine was collected at intervals of 2, 4, 6 and 8 h after initiation of the furosemide treatment, and the urine output and urinary excretion of furosemide and sodium were measured. The urinary excretion of furosemide was considered an indicator of drug efficacy. RESULTS The amount of sodium and furosemide excreted in urine showed no significant differences between the two groups; however, the mean of the urinary excretion of furosemide in the first 2 h after drug infusion was significantly higher (p = 0.03) in the furosemide/albumin group. No significant correlation between APACHE II scores and serum albumin levels and the urinary excretion of furosemide was seen. CONCLUSION The results indicated that there is not statistically significant differences between groups with furosemide alone and combined with albumin in urinary furosemide excretion. It seems that adding albumin for furosemide pharmacotherapy regime is not recommended as an intervention to increase furosemide efficacy in critically ill hypoalbuminemia patients. TRIAL REGISTRATION IRCT with the registration number IRCT201412132582N12 in 23 February 2015; https://en.irct.ir/trial/2356 Graphical abstract.
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Ono-Moore KD, Blackburn ML, Adams SH. Is palmitate truly proinflammatory? Experimental confounders and context-specificity. Am J Physiol Endocrinol Metab 2018; 315:E780-E794. [PMID: 30016150 DOI: 10.1152/ajpendo.00187.2018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Based primarily on cell culture results, saturated fatty acids (SFAs) are proposed to promote inflammation and contribute to metabolic dysfunction through Toll-like receptor activation. Studies are often complicated by a requirement for carriers (e.g., BSA) or solvents (e.g., ethanol) to increase SFA solubility. To ascertain whether these factors influence interpretations of SFA-associated inflammation activity, we measured responses of RAW264.7 monocyte/macrophages and C2C12 myotubes to various BSA, ethanol, and cyclodextrin (alternative FA carrier) conditions. Fatty acid-free, low-endotoxin BSA preparations (0.33% to 2% wt/vol) activated whereas 0.5-1.0% ethanol inhibited RAW264.7 TNFα release. Ethanol modestly increased IL-6 secretion in C2C12 myotubes. Cyclodextrins (0.3-6.0 mM) were tested as alternative carriers of palmitate, but their usefulness was limited due to toxicity and solubility issues. Using a lower-inflammation BSA source and no ethanol, ∼24-h sodium palmitate treatment (≤600 µM) failed to trigger RAW264.7 TNFα release and, in fact, significantly dampened BSA-induced inflammation by >50%. In C2C12 myotubes, only high palmitate concentrations (500-600 µM) elicited IL-6 secretion (>2.5-fold increase). Acute palmitate (200 or 500 µM) treatment did not activate MAP kinase pathways above that of fresh BSA-containing media alone in either cell type. These results highlight the importance of experimental conditions in studies exploring SFA inflammation effects. The limited (or even anti-inflammatory) effects of palmitate that we observed indicate that immunomodulatory effects of SFAs are context-specific. Thus, caution is needed when interpreting the literature related to putative proinflammatory effects of SFA.
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Affiliation(s)
| | - Michael L Blackburn
- Arkansas Children's Nutrition Center , Little Rock, Arkansas
- Department of Pediatrics, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - Sean H Adams
- Arkansas Children's Nutrition Center , Little Rock, Arkansas
- Department of Pediatrics, University of Arkansas for Medical Sciences , Little Rock, Arkansas
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Laki B, Taghizadeh-Ghehi M, Assarian M, Heidari K, Torkamandi H, Javadi MR, Gholami K. Effect of hospital-wide interventions to optimize albumin use in a tertiary hospital. J Clin Pharm Ther 2017; 42:704-709. [PMID: 28597926 DOI: 10.1111/jcpt.12566] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/02/2017] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Albumin has been frequently used as a therapeutic agent based on previous recommendations that are mostly controversial. Considering limited evidence-based indications, common inappropriate albumin use in many hospitals necessitates prompt educational and regulatory interventions. We performed this study to assess the effect of a hospital-wide programme to optimize albumin use in a tertiary referral university-affiliated hospital. METHODS This study was conducted in three 45-day phases, separated by two sequential interventions: guideline implementation and albumin order-sheet consideration. We evaluated albumin use and assessed its appropriateness in each phase at baseline, after guideline implementation and after order-sheet consideration. RESULTS We recorded 100, 93 and 71 albumin orders for 100, 84 and 66 patients during the first, second and third phases, respectively. The adjusted number of albumin orders (used albumin vials) was 94.9 (1481.7 vials), 80.8 (1037.6 vials) and 66 (1219 vials) in the first, second and third phases of the study, respectively. Albumin orders with appropriate indication increased significantly over the three phases of the study (OR=1.5, P=.008). The frequency of inappropriate orders reduced significantly from the first phase to the third phase (58%-27%, P=.007). WHAT IS NEW AND CONCLUSION The pattern and amount of albumin use changed following guideline implementation and order-sheet consideration, and inappropriate albumin use was reduced in our hospital. There was still room for improvement, particularly for indications that were not included in the guideline. Hence, a more comprehensive guideline, frequent audit, feedback and interactive educational approaches might be necessary to achieve results that are of a greater magnitude.
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Affiliation(s)
- B Laki
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - M Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - M Assarian
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - K Heidari
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - H Torkamandi
- Pharmaceutical Care Department, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - M R Javadi
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - K Gholami
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
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Su H, Wang Y, Gu Y, Bowman L, Zhao J, Ding M. Potential applications and human biosafety of nanomaterials used in nanomedicine. J Appl Toxicol 2017; 38:3-24. [PMID: 28589558 DOI: 10.1002/jat.3476] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 12/18/2022]
Abstract
With the rapid development of nanotechnology, potential applications of nanomaterials in medicine have been widely researched in recent years. Nanomaterials themselves can be used as image agents or therapeutic drugs, and for drug and gene delivery, biological devices, nanoelectronic biosensors or molecular nanotechnology. As the composition, morphology, chemical properties, implant sites as well as potential applications become more and more complex, human biosafety of nanomaterials for clinical use has become a major concern. If nanoparticles accumulate in the human body or interact with the body molecules or chemical components, health risks may also occur. Accordingly, the unique chemical and physical properties, potential applications in medical fields, as well as human biosafety in clinical trials are reviewed in this study. Finally, this article tries to give some suggestions for future work in nanomedicine research. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Hong Su
- Department of Preventative Medicine, Zhejiang Provincial Key Laboratory of Pathological and Physiological Technology, School of Medicine, Ningbo University, 818 Fenghua Road, Ningbo, Zhejiang Province, 315211, People's Republic of China
| | - Yafei Wang
- Department of Preventative Medicine, Zhejiang Provincial Key Laboratory of Pathological and Physiological Technology, School of Medicine, Ningbo University, 818 Fenghua Road, Ningbo, Zhejiang Province, 315211, People's Republic of China
| | - Yuanliang Gu
- Department of Preventative Medicine, Zhejiang Provincial Key Laboratory of Pathological and Physiological Technology, School of Medicine, Ningbo University, 818 Fenghua Road, Ningbo, Zhejiang Province, 315211, People's Republic of China
| | - Linda Bowman
- Toxicology and Molecular Biology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Morgantown, WV, 26505, USA
| | - Jinshun Zhao
- Department of Preventative Medicine, Zhejiang Provincial Key Laboratory of Pathological and Physiological Technology, School of Medicine, Ningbo University, 818 Fenghua Road, Ningbo, Zhejiang Province, 315211, People's Republic of China.,Toxicology and Molecular Biology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Morgantown, WV, 26505, USA
| | - Min Ding
- Toxicology and Molecular Biology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Morgantown, WV, 26505, USA
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Kitsios GD, Mascari P, Ettunsi R, Gray AW. Co-administration of furosemide with albumin for overcoming diuretic resistance in patients with hypoalbuminemia: a meta-analysis. J Crit Care 2013; 29:253-9. [PMID: 24268626 DOI: 10.1016/j.jcrc.2013.10.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 10/03/2013] [Accepted: 10/09/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE To systematically review clinical studies of co-administration of albumin and loop diuretics in hypoalbuminemic patients as a strategy to overcome diuretic resistance. MATERIALS AND METHODS Systematic search of electronic databases up to October 2012. We included randomized clinical trials of adults with hypoalbuminemia, comparing co-administration of loop diuretics and albumin versus loop diuretics alone. Quantitative data were synthesized with meta-analytic techniques for clinical, surrogate (urinary volume and urinary sodium excretion) and intermediate (pharmacokinetic and hemodynamic parameters) outcomes. RESULTS Ten studies were included, of which 8 trials with crossover design were synthesized with meta-analysis. A statistically significant increase in the amount of urine volume (increment of 231 mL [95% confidence interval 135.5-326.5]) and sodium excreted (15.9 mEq [4.9-26.8]) at 8 hours were found in favor of co-administration of albumin and furosemide. These differences were no longer statistically significant at 24 hours. Meta-analyses for intermediate outcomes (ie, furosemide excretion, distribution volume etc.) did not reveal statistically significant differences. CONCLUSIONS Synthesis of a heterogeneous body of evidence shows transient effects of modest clinical significance for co-administration of albumin with furosemide in hypoalbuminemic patients. Pragmatic, large-scale randomized studies are needed to delineate the role of this strategy.
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Affiliation(s)
- Georgios D Kitsios
- Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
| | - Paolo Mascari
- Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Riad Ettunsi
- Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Anthony W Gray
- Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
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Garcia-Garcia I, Gonzalez-Delgado CA, Valenzuela-Silva C, Hernandez-Bernal F, Ferrero-Bibilonia J, Soto-Hernandez R, Cervantes-Llano M, Ducongé J, Correa-Fernandez A, Olivera-Ruano L, Lopez-Saura P. Bioequivalence of two recombinant interferon alpha-2b liquid formulations in healthy male volunteers. Drugs R D 2009; 5:271-80. [PMID: 15357626 DOI: 10.2165/00126839-200405050-00003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE Interferon (IFN) alpha-2b is a protein with antiviral, antiproliferative and immunoregulatory properties that is approved for several clinical indications. A new liquid, albumin-free, IFNalpha-2b formulation has recently been developed. This study aimed to evaluate the equivalence of the pharmacokinetic, pharmacodynamic and safety properties of the new formulation with a reference one in healthy male volunteers. METHODS A randomised, crossover, double-blind study with a 3-week washout period was performed in which Heberon Alfa R (formulation A) and Viraferon (formulation B) were compared. A single 20 x 10(6) IU IFNalpha-2b dose was administered subcutaneously to 14 apparently healthy male subjects. Serum IFN level was measured over 48 hours by enzyme immunoassay (EIA) and by antiviral activity titration. Clinical and laboratory variables were determined, as were pharmacodynamic and safety criteria. RESULTS Groups were homogeneous with regard to all demographic and baseline variables. Pharmacokinetic comparison by EIA did not show differences between the formulations: area under the curve (AUC) 2572 versus 2561 ng x h/L, maximum plasma concentration (Cmax) 318 versus 354 ng/L, time to Cmax (tmax) 8.2 versus 8.5 h, elimination half-life (t(1/2)) 5.87 versus 6.08 h, terminal elimination rate (lambda) 0.122 versus 0.118 h(-1), and mean residence time (MRT) 10.9 versus 12.0 h for formulations A and B, respectively. The differences never reached 20%, which is the clinically significant threshold. The 90% confidence interval of the ratio between them was in all cases within the 0.8, 1.25 range. The two formulations were clinically equivalent with regard to serum IFN antiviral activity titration (0.8, 1.25 criterion) regarding their pharmacokinetic parameters. There were no significant differences with respect to the pharmacodynamic variables: serum beta2-microglobulin and temperature increase. Heart rate and blood pressure changes did not differ either. Both products provoked similar haematological count decreases and had similar safety profiles. The most frequent adverse reactions were fever, tachycardia, headache and arthralgias. CONCLUSION The overall analysis strongly suggests the bioequivalence of these two products.
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Abstract
Widespread destruction of the skin induces a large necrotic mass and a break of the skin barrier. It also leads to an intense inflammatory reaction. This activates keratinocytes, endothelial cells and neutrophils. Certain mediators (e.g. endothelin, histamine, bradykinin, serotonin, catecholamines, vasopressin, prostaglandins, cytokines and nitrogen monoxide) are thus released in large quantities and act both at the site of the burns and at a distance. The abnormally high level of albumin in the capillary wall and the increased capacity of absorption of the interstitial areas around the burns are the main abnormalities observed. This results in a hypovolemia associated with a hemoconcentration, hyponatremia, hypoalbuminemia, systemic vasoconstriction and myocardial malfunction, which is difficult to evidence. During the initial phase, the major risk is the appearance of hypovolemic shock, which is rapidly irreversible if early treatment is not administered. Vascular filling with iso- or hyper-osmolar sodium crystalloids, associated with buffer solutions, is the first line. There is still debate regarding the best moment at which to give albumin. A hyperkinetic shock may occur after several hours and despite the filling. The symptoms are tachycardia, increased heart rate and a dramatic decrease in systemic vascular resistance. This may lead to metabolic acidosis and multi-organ failure. Study of the hemodynamic profile of the patient allows the rational use of pressor amines and haemodialysis.
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Affiliation(s)
- R Sanchez
- Service des brûlés, CHU de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux, France.
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Wray-Cahen D, Caperna TJ, Steele NC. Methyl-beta-cyclodextrin: an alternative carrier for intravenous infusion of palmitate during tracer studies in swine (Sus scrofa domestica). Comp Biochem Physiol A Mol Integr Physiol 2001; 130:55-65. [PMID: 11672683 DOI: 10.1016/s1095-6433(01)00369-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Fatty acid-free albumin has been the standard carrier for intravenous infusion of fatty acids to study in vivo lipid metabolism. However, subjects can have adverse reactions to infusion of albumin. We sought an alternative to albumin as a carrier for intravenous infusion of fatty acids, using the pig as a model. Cyclodextrins are naturally occurring water-soluble molecules that can serve as carriers for lipid-soluble compounds. 13C-palmitate was complexed to either 20% methyl-beta-cyclodextrin, 20% 2-hydroxypropyl-beta-cyclodextrin, or 5% porcine albumin (isotopic purity of infusates: 99.22+/-0.06%). 13C-palmitate-albumin was infused under fed conditions and 13C-palmitate-methyl-beta-cyclodextrin was infused under fasted and fed conditions in 50-kg pigs. Palmitate remained in solution at 4 degrees C in methyl-beta-cyclodextrin, but precipitated at 25-30 degrees C in 2-hydroxypropyl-beta-cyclodextrin. Pigs infused with 13C-palmitate-methyl-beta-cyclodextrin maintained normal body temperature and appetite; those infused with 13C-palmitate-albumin became anorexic and exhibited other negative side effects to albumin. Palmitate oxidation rates under fed conditions were similar using either 13C-palmitate-methyl-beta-cyclodextrin or 13C-palmitate-albumin complexes. Fasting increased 13C-palmitate-methyl-beta-cyclodextrin oxidation by approximately eight-fold. These data suggest that methyl-beta-cyclodextrin may be a suitable substitute for albumin in fatty acid metabolism studies in swine.
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Affiliation(s)
- D Wray-Cahen
- USDA-ARS, Livestock and Poultry Science Institute, Growth Biology Laboratory, Beltsville, MD 20705, USA.
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Bar-Or D, Rael LT, Lau EP, Rao NK, Thomas GW, Winkler JV, Yukl RL, Kingston RG, Curtis CG. An analog of the human albumin N-terminus (Asp-Ala-His-Lys) prevents formation of copper-induced reactive oxygen species. Biochem Biophys Res Commun 2001; 284:856-62. [PMID: 11396981 DOI: 10.1006/bbrc.2001.5042] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Copper mobilization and redox activity form damaging reactive oxygen species (ROS) and are implicated in the pathogenesis of ischemia-reperfusion injury, chronic inflammation, Alzheimer's disease, aging, and cancer. Protein sequestration of Cu(II) ions has been shown to prevent ROS-generating reactions. The first four amino acids of the N-terminus of human albumin, Asp-Ala-His-Lys (DAHK), form a tight binding site for Cu(II) ions. We synthesized several analogs, including the enantiomer d-DAHK, to study their effects on copper-induced hydroxyl radical and superoxide formation in the presence of ascorbate. d-DAHK prevented thiobarbituric acid-reactive species (TBARS) formation within physiological and acidic pH ranges (7.5-6.5) and inhibited low-density lipoprotein lipid peroxidation. A d-DAHK/Cu complex exhibited superoxide dismutase-like activity by significantly inhibiting superoxide formation. These in vitro results suggest that d-DAHK may shift the Cu(II)-binding equilibrium from the exchangeable Cu(II) pool to the tightly-bound, nonexchangeable pool, prevent ROS formation, and potentially provide therapeutic benefit for ROS-related diseases.
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Affiliation(s)
- D Bar-Or
- Department of Trauma Research, Swedish Medical Center, Englewood, Colorado 80110, USA.
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Finelli C, Alfano V, Pasanisi F, Marra M, Violante G, Alfonsi L, Scalfi L, Contaldo F. Use and abuse of albumin: a survey of clinical records from an internal medicine ward. Clin Nutr 2001; 20:183-5. [PMID: 11327749 DOI: 10.1054/clnu.2000.0390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS This study was to review albumin prescriptions and indications in 4122 patients hospitalized in internal medicine wards in the years 1996, 1998 and 1999, before and after the ad hoc regulations issued in 1997 by the Italian Ministry of Health. METHODS In 1996 (n=63), 1998 (n=59) and 1999 (n=55) 177 of these patients (4.3%) were given i.v. albumin. RESULTS 161 (91%) of them had serum albumin values of <3.5 g/dl, while in only 36% were these values <2.5 g/dl. CONCLUSION In the majority of cases albumin was erroneously prescribed, often to enhance diuretic efficacy or in protein energy malnutrition. Its prescription has not been influenced by the new recommendations.
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Affiliation(s)
- C Finelli
- Dipartimento di Medicina Clinica e Sperimentale, Università Federico II di Napoli, Italy
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Erstad BL. Pharmacoeconomic comparison of an albumin-furosemide complex versus sequential therapy for renal insufficiency. Clin Ther 1999; 21:1380-6. [PMID: 10485509 DOI: 10.1016/s0149-2918(99)80038-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this economic analysis was to develop an economic model using intra-institutional cost data for acute, oliguric renal insufficiency treated with either an albumin-furosemide complex or albumin followed by furosemide (sequential therapy). The perspective of this study was from the standpoint of the institution (University Medical Center, a teaching hospital). The decision tree and sensitivity analyses demonstrated that the albumin-furosemide complex would be more effective and less costly than sequential therapy for a range of outcome probabilities. Using effectiveness assumptions from published literature, the complex could avoid dialysis in 27% of patients compared with 8% of patients receiving sequential therapy. The complex would also be less costly ($7778 vs $8748). In terms of cost-effectiveness, the complex is $28,807 per averted dialysis compared with $109,350 for sequential therapy.
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Affiliation(s)
- B L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson 85721-0207, USA
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Tjoeng MM, Bartelink AK, Thijs LG. Exploding the albumin myth. PHARMACY WORLD & SCIENCE : PWS 1999; 21:17-20. [PMID: 10214663 DOI: 10.1023/a:1008637528580] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In this article arguments are given to stop the current practise of infusing albumin in patients in shock and low levels of serum albumin. Correcting the albumin levels is not correlated with better survival or change in morbidity. Fluid therapy including the use of synthetic plasma expanders is the accepted therapy for patients in sceptic shock.
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Affiliation(s)
- M M Tjoeng
- Dept Clinical Pharmacology, Eemland Hospital, Amersfoort, The Netherlands
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Erstad BL, Richards H, Rose S, Nakazato P, Fortune J. Influence of twenty-five per cent human serum albumin on total and ionized calcium concentrations in vivo. Crit Care 1999; 3:117-121. [PMID: 11056734 PMCID: PMC29024 DOI: 10.1186/cc353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/1999] [Revised: 07/15/1999] [Accepted: 07/19/1999] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: A inverse correlation has been found between changes in ionized calcium concentrations and the addition of albumin in vitro, which may explain adverse cardiovascular effects attributed to exogenous albumin in vivo. The purpose of this investigation was to determine the interaction (if any) between exogenous 25% albumin administration (100 ml given over < 30 min) and calcium concentrations in patients, all but one of whom were in an intensive care unit. RESULTS: There were no significant differences in the ionized calcium concentrations obtained before, at the end and 6 h after the administration of albumin (1.09 +/- 0.23, 1.06 +/- 0.22, 1.06 +/- 0.21 mmol/l, respectively). Similarly, there were no significant differences in the total calcium concentrations between these same time periods (2.03 +/- 0.18, 2.05 +/- 0.20, 2.08 +/- 0.23 mmol/l, respectively). CONCLUSIONS: In patients receiving infusions of 25% albumin, it appears that circulating calcium concentrations are well regulated by homeostatic mechanisms. Albumin infusions had no effect on calcium concentrations, although it is possible that temporary changes of questionable clinical importance may have occurred between measurement periods.
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Affiliation(s)
- Brian L Erstad
- Arizona Health Sciences Center, Departments of Pharmacy Practice
and Science and Surgery, Tucson, Arizona, USA
| | - Hal Richards
- Arizona Health Sciences Center, Departments of Pharmacy Practice
and Science and Surgery, Tucson, Arizona, USA
| | - Susan Rose
- Arizona Health Sciences Center, Departments of Pharmacy Practice
and Science and Surgery, Tucson, Arizona, USA
| | - Paul Nakazato
- Arizona Health Sciences Center, Departments of Pharmacy Practice
and Science and Surgery, Tucson, Arizona, USA
| | - John Fortune
- Arizona Health Sciences Center, Departments of Pharmacy Practice
and Science and Surgery, Tucson, Arizona, USA
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The Use of Serum Albumin as a Prognostic or Nutritional Marker and The Pros and Cons of IV Albumin Therapy. Nutr Clin Pract 1998; 13:110-122. [DOI: 10.1002/j.1941-2452.1998.tb03058.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Sheridan RL, Prelack K, Cunningham JJ. Physiologic hypoalbuminemia is well tolerated by severely burned children. THE JOURNAL OF TRAUMA 1997; 43:448-52. [PMID: 9314306 DOI: 10.1097/00005373-199709000-00010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Physiologic hypoalbuminemia, defined as a plasma albumin (pl-ALB) of 1.0 to 2.5 g/dL, is a component of the injury response. A consensus on the need for albumin supplementation in this setting is lacking. METHODS We examined 27 consecutive children (age, 7 +/- 6 years) with > 40% body surface burns (mean, 59 +/- 18%) during their initial 4 weeks of care. Patients were managed with an albumin-supplementation protocol that tolerated profound physiologic hypoalbuminemia. Intravenous albumin was administered by infusion of 1 to 2 g/kg/d when pl-ALB fell below 1.0 g/dL, or below 1.5 g/dL in the presence of enteral feeding intolerance or pulmonary dysfunction. Supplementation was stopped when pl-ALB reached 2.0 g/dL. RESULTS Mean pl-ALB was 1.7 g/dL overall. Infusion for pl-ALB < 1.0 g/dL was needed for 70% (n = 19) of the patients. Profound physiologic hypoalbuminemia was constant, that is, mean weekly pl-ALB never exceed 2.5 g/dL in any patient. Mean plasma globulin rose during the 4 week period from 2.3 +/- 0.1 at week 1 to 3.1 +/- 0.1 at week 4. Diarrhea was negligible (19 of 756 patient days), nasogastric feedings were well tolerated, PaO2/FiO2 ratios remained well above 150, wounds healed satisfactorily, and all children survived and have been discharged home. CONCLUSIONS Profound physiologic hypoalbuminemia (pl-ALB of 1.0-2.5 g/dL) does not have adverse effects on pulmonary or gut function, wound healing, or outcome in severely burned children, perhaps because of a compensatory increase in acute-phase proteins reflected in plasma globulin.
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Affiliation(s)
- R L Sheridan
- Shriners Burns Institute, Massachusetts General Hospital, Boston 02114, USA.
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Affiliation(s)
- B B Warren
- Department of Anesthesiology, University of Virginia, Charlottesville, USA
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Sanchez R. [Role of albumins in burnt patients: its efficacy during intensive care. Addendum to the expert guidelines of the Consensus Conference, Paris December 15th 1995]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1996; 15:1124-9. [PMID: 9180993 DOI: 10.1016/s0750-7658(96)89488-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the burned patient, the critical threshold over which a correction of hypoalbuminemia is required has not yet been clearly defined. The level of 30 g.L-1 of albumin is usually admitted. According to the extent of the burn, albumin is not indicated in patients with a burn size below 15% of the total body surface. It is essential, from the very beginning of management in patients with a burn size over 50%. Its administration can be postponed to the 8th, 12th or even 24th hour in case of a burn size between 15 and 50%.
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Affiliation(s)
- R Sanchez
- Service des brûlés, groupe hospitalier Pellegrin-Tripode, Bordeaux, France
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Abstract
BACKGROUND IV albumin has been advocated as adjunctive therapy for hypoalbuminemic patients who are receiving nutrition support. This discussion will critically consider the rationale for this recommendation as well as the evidence available in the medical literature. METHODS The medical literature was reviewed. RESULTS Randomized controlled trials have shown that IV albumin improves serum albumin levels. However such therapy does not improve clinical outcome in patients receiving parenteral nutrition. Although no trials exist that test the hypothesis in hypoalbuminemic patients receiving enteral nutrition, the purported "supportive evidence" in the medical literature is actually weak and contradictory. IV albumin does have some associated toxicity, and it is expensive. CONCLUSIONS There is reason to believe that IV albumin is not effective in improving the clinical outcome of hypoalbuminemic patients who are receiving nutrition support. Until more compelling data become available, it is not reasonable to adopt a policy of routinely correcting the hypoalbuminemia in this way. In fact, hypoalbuminemia may be a manifestation of a serious disease state rather than a marker of deficient protein stores.
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Affiliation(s)
- R L Koretz
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar 91342, USA
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Zhi J, Teller SB, Satoh H, Koss-Twardy SG, Luke DR. Influence of human serum albumin content in formulations on the bioequivalency of interferon alfa-2a given by subcutaneous injection in healthy male volunteers. J Clin Pharmacol 1995; 35:281-4. [PMID: 7608317 DOI: 10.1002/j.1552-4604.1995.tb04059.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To determine the influence of human serum albumin (HSA) content in formulations on the bioequivalency of recombinant interferon alfa-2a, a double-blind, randomized, two-way crossover study was conducted in 24 healthy male volunteers. Subjects received a single subcutaneous injection of 18 million IU of Roferon-A reconstituted with either the diluent containing 10 mg of HSA or the HSA-free diluent; final HSA contents in the 2 formulations were 15 mg and 5 mg, respectively. Administration of the 2 formulations resulted in similar 48-hour Roferon-A serum concentration-time profiles and comparable frequency and intensity of adverse events. The statistical analysis using the two one-sided tests procedure showed that both formulations were bioequivalent for pharmacokinetic parameters such as Cmax, tmax, AUC48, and AUC. We conclude that a threefold change in HSA content in formulations does not alter the bioequivalency of Roferon-A.
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Affiliation(s)
- J Zhi
- Hoffmann-La Roche, Inc., Nutley, NJ 07110-1199, USA
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Abstract
Reactions to human serum albumin (HSA) in therapeutic plasma exchange (TPE) are rare. Nevertheless, older literature describes possible adverse effects, including specific immune responses to albumin or other proteins, and reactions due to contaminating organisms or pyrogen. During an eight day period three patients in our unit had unusual reactions after infusion of 1.5-2 L of HSA. Patient 1 had trembling that persisted for 20 min. Patient 2 had shaking for 40 min despite calcium gluconate infusion, and fever to 100.8 degrees F. Patient 3 had severe rigors that subsided after 90 min when meperidine was finally given, and fever to 103.5 degrees F. Record reviews revealed that all three patients had received HSA from the same lot, and that only one other TPE patient had received HSA from that lot. Neither our pharmacy nor the manufacturer was aware of other reactions associated with that lot. Material from a bottle only partially infused to patient 3 was negative in culture and was negative for pyrogen when retested by the manufacturer. Nevertheless, because patients 1 and 2 had each had multiple previous uneventful TPEs and because all three patients tolerated subsequent TPEs without incident when another brand of HSA was used, we conclude that these patients had pyrogen reactions to the implicated HSA lot. This experience illustrates the value of cluster recognition in arousing suspicion of unusual reactions to HSA and the value of recorded lot numbers in pursuing such suspicions. Apheresis personnel should be aware of the potential for pyrogen reactions with HSA and should record lot numbers of all fluids infused during TPE.
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Affiliation(s)
- M Pool
- Department of Pathology, Rush Presbyterian St. Luke's Medical Center, Chicago, IL 60612, USA
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Abstract
OBJECTIVE To review the administration of exogenous albumin in patients receiving nutritional support and determine if the use of albumin is supported by controlled trials. DATA SOURCES MEDLINE search of English-language literature using the key terms albumin, parenteral nutrition, and enteral nutrition. The references of articles identified were also searched. STUDY SELECTION Studies examining the administration of exogenous albumin to hypoalbuminemic patients receiving nutrition support. DATA EXTRACTION Results from prospective randomized trials are presented in detail. Data from noncontrolled and animal studies are presented in areas where human controlled trials are limited. DATA SYNTHESIS Albumin is a marker of malnutrition and numerous studies have demonstrated that a low serum albumin concentration is associated with increased morbidity and mortality. Investigators have attempted to improve outcome through the administration of exogenous albumin. The results of controlled trials examining exogenous albumin administration have been equivocal. One study demonstrated a significant decrease in overall complications, pneumonia, and sepsis. In two other controlled trials, albumin administration failed to decrease complications. None of the studies demonstrated a significant decrease in mortality or length of stay. A low serum albumin concentration has also been linked to intolerance to enteral feedings. Although case reports and one study support the administration of albumin, two prospective controlled trials have failed to demonstrate improved tolerance to enteral feeding in hypoalbuminemic patients receiving exogenous albumin. CONCLUSIONS Evidence to date is insufficient to support the routine administration of exogenous albumin to hypoalbuminemic patients receiving nutrition support.
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Affiliation(s)
- R G D'Angio
- Presbyterian Healthcare Services, Albuquerque, NM
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