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

Non-immunoglobin scaffold binders as efficient affinity ligands for purification of broad-spectrum serum albumins

Although non-immunoglobin scaffold binders with high affinity and broad spectrum for albumin are attractive for lab-scale albumin purification, affinity chromatography based on these binders has not been developed. Here, the albumin-binding capabilities of representative binders, including protein G-derived albumin binding domain (ABD), albumin binding nanofitins (ABNF), and human serum albumin affimer 31 (HSA31) were predicted by interaction structure analysis and verified by experimental assays. Interaction structure prediction suggested that ABD possessed great potential to bind human (HSA), rhesus monkey (RhSA), mouse (MSA), and rat serum albumin (RSA), whereas ABNF might only bind HSA and bovine serum albumin (BSA), and HSA31 might not bind any of the tested albumins. Subsequent experimental assays demonstrated that ABD was similar to ABNF in HSA and RhSA binding but was superior to ABNF in MSA and RSA binding. ABNF exhibited greater BSA-binding capability than that exhibited by ABD. Both ABD and ABNF showed little binding to rabbit serum albumin (RbSA) and HSA31 showed no binding to all tested albumins. ABD and ABNF could be conjugated to prepackaged NHS-activated HP columns at similar ligand densities. For purification of albumin from plasma, the yields of ABD-HP column for HSA, RhSA, MSA, and RSA were approximately 20 mg, which was 3-4 times higher than that of ABNF-HP column using either Gly-HCl or sodium caprylate as elution buffer. Notably, BSA could only be recovered from plasma using ABNF-HP column with a yield of 5-8 mg. However, little albumin could be purified using HSA31-HP column. These results indicate that both ABD- and ABNF-HP columns could be used as novel tools for purification of broad-spectrum albumins.

The role of serum albumin in critical illness, predicting poor outcomes, and exploring the therapeutic potential of albumin supplementation

OBJECTIVE

Serum albumin (ALB) plays a vital role in maintaining oncotic pressure and contributing to hemodynamic stability, with low levels associated with adverse outcomes in critically ill patients. This study aimed to assess the association between serum ALB concentrations and poor outcomes and the possible benefits of ALB supplementation.

METHODS

A retrospective study involving 300 intensive care unit (ICU) patients. Albumin levels were recorded upon admission and throughout the stay, and patients were categorized based on a cutoff of 2.49 g/dl. The associations between low ALB levels and mortality were assessed using regression analysis. Additionally, it investigated the association of albumin supplementation with patient outcomes and mortality in specific patient populations.

RESULTS

The mean age was 54.9 years, with 68% having sepsis. Patients with low baseline ALB concentrations exhibited higher overall mortality (71% vs. 52%) and 28-day mortality (50% vs. 39%). Adjusted analyses confirmed associations with mortality. Albumin supplementation was administered to 53% of the patients. Its use demonstrated potential benefits, particularly in reducing mortality, when given to specific groups, such as sepsis and hypoalbuminemia patients.

DISCUSSION

The study confirms that low serum albumin levels are strongly associated with higher mortality rates in ICU patients. Albumin supplementation showed potential benefits, particularly in patients with sepsis and low albumin levels. Further analyses explored the dosage-response relationship and identified potential groups that would benefit from albumin supplementation.

CONCLUSION

Albumin can play a major role in predicting mortality in critically ill patients. Moreover, ALB supplementation may improve survival, especially in resource-limited settings. Future research should refine protocols through clinical trials for optimal survival in critically ill patients.

Surgical risk stratification in patients with cirrhosis

Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.

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.