Moderator Effect of Hypoalbuminemia in Volume Resuscitation and Plasma Expansion with Intravenous Albumin Solution

Fluid management of acute kidney injury

PURPOSE OF REVIEW

Acute kidney injury (AKI) is commonly encountered in critical care medicine as is intravenous fluid therapy. It is accepted that there is interplay between fluid use and AKI, both potentially positive and negative. An understanding of the physiological rationale for fluid is important to help clinicians when considering fluid therapy in patients with, or at risk for AKI; this includes understanding choice of fluid, method of monitoring, administration and clinical sequelae.

RECENT FINDINGS

There is increasing interest in combining both static and dynamic measures to assess fluid balance, fluid responsiveness effects of fluid therapy, which are areas requiring ongoing study to translate this theory into clinically useful practice at the bedside. Whilst the debate of choice of crystalloid in ICU practice continues, further evidence for benefits for balanced solutions emerges in the form of international guidelines and patient data meta-analysis of previously performed trials.

SUMMARY

This review assesses the physiological rationale for fluid use in ICU cohorts with AKI of various types, as well as a systematic approach for choice of fluid therapy using a number of different variables, which aims to help guide clinicians in managing fluid use and fluid balance in critically ill patients with AKI.

Albumin in Normovolemic Fluid Management for Severe Traumatic Brain Injury: Controversies and Research Gaps

Traumatic brain injury (TBI) is a significant public health issue characterized by high mortality rates and long-term complications. This commentary examines the controversial role of the use of albumin in the fluid management of patients with severe TBI. Despite its physiological benefits, the clinical use of albumin remains controversial due to the fact that various studies have yielded mixed results. Serum albumin is important for maintaining normovolemia, primarily through its contribution to colloid osmotic pressure, which helps to retain fluid in the circulatory system. This review highlights the existing evidence, examines inconsistencies in guideline recommendations, and suggests future research directions to clarify the efficacy and safety of the use of albumin in maintaining normovolemia in patients with TBI. The review also discusses the potential benefits of small-volume resuscitation strategies for the management of acute kidney injury in TBI patients, drawing parallels with the management of septic acute kidney injury. The need for further well-designed randomized controlled trials and ethical considerations in studies regarding the use of hyperoncotic albumin in TBI management is emphasized.

Incidence and associated factors for hypotension during continuous renal replacement therapy in critically ill patients

AIMS

This work aimed to analyse retrospective data on hypotension incidence and associated factors among patients requiring continuous renal replacement therapy.

BACKGROUND

The incidence and risk factors of continuous renal replacement therapy-related hypotension have not been adequately explored.

DESIGN

The study was designed as a retrospective analysis.

METHODS

Patients who required continuous renal replacement therapy in the ICU between January 2017 and June 2021 were reviewed. The multivariate logistic regression model was used to determine the associated factors of hypotension.

RESULTS

Hypotension occurred in 242 out of 885 circuits (27.3%) among 140 patients. The logistic regression analysis identified seven factors associated with the occurrence of hypotension during CRRT: serum albumin (OR = 0.969, 95%CI: 0.934-0.999), serum calcium (OR = 0.514, 95%CI: 0.345-0.905), CO2CP (OR = 0.933, 95%CI: 0.897-0.971), use of vasopressors (OR = 5.731, 95%CI: 4.023-8.165), hypotension before CRRT initiation (OR = 2.779, 95%CI:1.238-6.242), age (OR = 1.016, 95%CI: 1.005-1.027), and fluid removal rate (OR = 1.002, 95%CI: 1.001-1.003).

CONCLUSIONS

Hypotension frequently occurs in patients receiving continuous renal replacement therapy, especially in the early stages. Multiple factors can be associated with cardiac output or peripheral resistance changes, including excessive ultrafiltration, vasopressors, serum albumin and serum calcium levels, and carbon dioxide combining power.

Stable Nitroxide as Diagnostic Tools for Monitoring of Oxidative Stress and Hypoalbuminemia in the Context of COVID-19

Oxidative stress is a major source of ROS-mediated damage to macromolecules, tissues, and the whole body. It is an important marker in the severe picture of pathological conditions. The discovery of free radicals in biological systems gives a "start" to studying various pathological processes related to the development and progression of many diseases. From this moment on, the enrichment of knowledge about the participation of free radicals and free-radical processes in the pathogenesis of cardiovascular, neurodegenerative, and endocrine diseases, inflammatory conditions, and infections, including COVID-19, is increasing exponentially. Excessive inflammatory responses and abnormal reactive oxygen species (ROS) levels may disrupt mitochondrial dynamics, increasing the risk of cell damage. In addition, low serum albumin levels and changes in the normal physiological balance between reduced and oxidized albumin can be a serious prerequisite for impaired antioxidant capacity of the body, worsening the condition in patients. This review presents the interrelationship between oxidative stress, inflammation, and low albumin levels, which are hallmarks of COVID-19.

siRNA-mediated reduction of a circulating protein in swine using lipid nanoparticles

Genetic manipulation of animal models is a fundamental research tool in biology and medicine but is challenging in large animals. In rodents, models can be readily developed by knocking out genes in embryonic stem cells or by knocking down genes through in vivo delivery of nucleic acids. Swine are a preferred animal model for studying the cardiovascular and immune systems, but there are limited strategies for genetic manipulation. Lipid nanoparticles (LNPs) efficiently deliver small interfering RNA (siRNA) to knock down circulating proteins, but swine are sensitive to LNP-induced complement activation-related pseudoallergy (CARPA). We hypothesized that appropriately administering optimized siRNA-LNPs could knock down circulating levels of plasminogen, a blood protein synthesized in the liver. siRNA-LNPs against plasminogen (siPLG) reduced plasma plasminogen protein and hepatic plasminogen mRNA levels to below 5% of baseline values. Functional assays showed that reducing plasminogen levels modulated systemic blood coagulation. Clinical signs of CARPA were not observed, and occasional mild and transient hepatotoxicity was present in siPLG-treated animals at 5 h post-infusion, which returned to baseline by 7 days. These findings advance siRNA-LNPs in swine models, enabling genetic engineering of blood and hepatic proteins, which can likely expand to proteins in other tissues in the future.

Association of easy albumin-bilirubin score with increased mortality in adult trauma patients

INTRODUCTION

The easy albumin-bilirubin (EZ-ALBI) score is calculated using the equation: total bilirubin (mg/dl) - 9 × albumin (g/dl), and is used to evaluate liver functional reserve. This study was designed to investigate whether the EZ-ALBI score serves as an independent risk factor for mortality and is useful for stratifying the mortality risk in adult trauma patients.

METHODS

We retrospectively reviewed data from the registered trauma database of the hospital and included 3,637 adult trauma patients (1,241 deaths and 2,396 survivors) due to all trauma caused between January 1, 2009, and December 31, 2021. The patients were allocated to the two study groups based on the best EZ-ALBI cutoff point (EZ-ALBI = -28.5), which was determined based on the area under the receiver operating characteristic curve.

RESULTS

Results revealed that the non-survivors had a significantly higher EZ-ALBI score than the survivors (-26.4 ± 6.5 vs. -31.5 ± 6.2, p < 0.001). Multivariate logistic regression analysis revealed that EZ-ALBI ≥ -28.5was an independent risk factor for mortality (odds ratio, 2.31; 95% confidence interval, 1.63-3.28; p < 0.001). Patients with an EZ-ALBI score ≥ -28.5 presented with 2.47-fold higher adjusted mortality rates than patients with an EZ-ALBI score < -28.5. A propensity score-matched pair cohort of 1,236 patients was developed to reduce baseline disparities in trauma mechanisms. The analysis showed that patients with an EZ-ALBI score ≥ -28.5 had a 4.12 times higher mortality rate compared to patients with an EZ-ALBI score < -28.5.

CONCLUSION

The EZ-ALBI score was a significant independent risk factor for mortality and can serve as a valuable tool for stratifying mortality risk in adult trauma patients by all trauma causes.

Clinical value of the red blood cell distribution width to albumin ratio in the assessment of prognosis in critically ill patients with sepsis: a retrospective analysis

Background

Red blood cell (RBC) distribution width (RDW) to albumin ratio is a novel biomarker and its prognostic effect on critically ill patients with sepsis has not been extensively investigated. The objective of this study was to identify the prognostic value of the RDW to albumin ratio in these patients.

Methods

Data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. A Cox proportional hazards model and restricted cubic spline model were used to determine the association of RDW to albumin ratio with mortality. Receiver operating characteristic (ROC) curves and Kaplan-Meier survival curves were applied, and the area under the curve (AUC) was used to compare the predictive value.

Results

A total of 3,969 eligible patients were enrolled. The median RDW to albumin ratio was significantly higher in non-survivors than in survivors at 30 and 90 days. Patients were divided into groups according to the RDW to albumin ratio, and the risk of 30- and 90-day mortality markedly increased in the group with a higher ratio. The relationship between the RDW to albumin ratio as a continuous variable and 30-day mortality also showed an upward trend in the restricted cubic spline. The AUC of the RDW to albumin ratio was 0.633 in discriminating 30-day mortality which was similar to that of the lactate to albumin ratio (AUC =0.617; P=0.133) and higher than that of the neutrophil percentage to albumin ratio (AUC =0.559; P<0.001).

Conclusions

The RDW to albumin ratio is a promising biomarker for assessing the prognosis of critically ill patients with sepsis. Its predictive value in determining mortality was found to be similar to that of the lactate to albumin ratio and superior to that of the neutrophil percentage to albumin ratio.

Controversies Surrounding Albumin Use in Sepsis: Lessons from Cirrhosis

This narrative review critically examines the role of albumin in sepsis management and compares it to its well-established application in liver cirrhosis. Albumin, a key plasma protein, is effective in the management of fluid imbalance, circulatory dysfunction, and inflammation-related complications. However, its role in sepsis is more intricate and characterized by ongoing debate and varied results from clinical studies. In sepsis, the potential benefits of albumin include maintaining vascular integrity and modulating inflammation, yet its consistent clinical efficacy is not as definitive as that in cirrhosis. This review evaluated various clinical trials and evidence, highlighting their limitations and providing practical insights for clinicians. It emphasizes identifying sepsis patient subgroups that are most likely to benefit from albumin therapy, particularly exploring the correction of hypoalbuminemia. This condition, which is significantly corrected in patients with cirrhosis, may have similar therapeutic advantages in sepsis. The potential effectiveness of albumin in the low-volume resuscitation and deresuscitation phases of sepsis management was noted. Given the safety concerns observed in cirrhosis, such as pulmonary edema and hypervolemia associated with albumin therapy, cautious integration of albumin into sepsis treatment is mandatory. Personalized albumin therapy is advocated for tailoring strategies to the specific needs of each patient, based on their clinical presentation and underlying conditions. The need for further research to delineate the role of albumin in sepsis pathophysiology is underscored. The review emphasizes the importance of conducting trials to assess the effectiveness of albumin in correcting hypoalbuminemia in sepsis, its impact on patient outcomes, and the establishment of appropriate dosing and administration methods. This approach to albumin use in sepsis management is posited as a way to potentially improve patient outcomes in this complex clinical scenario while being mindful of the lessons learned from its use in cirrhosis.

Human Albumin Infusion in Critically Ill and Perioperative Patients: Narrative Rapid Review of Meta-Analyses from the Last Five Years

BACKGROUND

Human albumin, a vital plasma protein with diverse molecular properties, has garnered interest for its therapeutic potential in various diseases, including critical illnesses. However, the efficacy of albumin infusion in critical care and its associated complications remains controversial. To address this, a review of recent meta-analyses was conducted to summarize the evidence pertaining to albumin use in critical illness.

METHODS

Adhering to the rapid review approach, designed to provide a concise synthesis of existing evidence within a short timeframe, relevant meta-analyses published in the last five years were identified and analyzed. PubMed, Embase, and Cochrane databases of systematic reviews were searched using pre-defined search terms. Eligible studies included meta-analyses examining the association between albumin infusion and outcomes in critically ill and perioperative patients.

RESULTS

Twelve meta-analyses were included in the review, covering diverse critical illnesses and perioperative scenarios such as sepsis, cardiothoracic surgery, and acute brain injury. The analyses revealed varying levels of evidence for the effects of albumin use on different outcomes, ranging from no significant associations to suggestive and convincing.

CONCLUSIONS

Albumin infusion stabilizes hemodynamic resuscitation endpoints, improves diuretic resistance, and has the potential to prevent hypotensive episodes during mechanical ventilation in hypoalbuminemic patients and improve the survival of patients with septic shock. However, caution is warranted due to the methodological limitations of the included studies. Further high-quality research is needed to validate these findings and inform clinical decision-making regarding albumin use in critical care.

Serum Albumin in Health and Disease: From Comparative Biochemistry to Translational Medicine

Being one of the main proteins in the human body and many animal species, albumin plays a decisive role in the transport of various ions, electrically neutral molecules and in maintaining the colloid osmotic pressure of the blood [...].