Association between albumin administration and survival in cardiac surgery: a retrospective cohort study

  • Kingeter AJ, Raghunathan K, Munson SH, Hayashida DK, Zhang X, Iyengar S, et al.
  • Can J Anaesth. 2018;65(11):1218–1227

The choice of fluid administered during cardiac surgery remains a debated topic, often focussed around colloid solutions containing albumin. Conflicting results from numerous studies have left questions over albumin safety and potential to be superior to crystalloids during surgery. Kingeter et al. hoped to achieve clarity on this controversial topic in a retrospective study of cardiac surgery outcomes over a 12-year period.

Fluid therapy is an essential element during cardiac surgery, and intravenous colloid solutions containing human-derived albumin are commonly administered (Frenette et al., 2014; Jiang & Shaw, 2016). Does albumin use offer more clinical benefits than alternative crystalloid solutions?

Potential benefits of albumin use during cardiac surgery include decreases in inflammation and platelet activation, and possible antioxidant effects (Fanali et al., 2012; Bruschi et al., 2013). It has also been suggested that during cardiopulmonary bypass (CPB) surgery, albumin has a positive effect on the endothelial glycocalyx degradation pathway which may prevent adverse effects of surgery (Ohqvist et al., 1981a; Ohqvist et al., 1981b; Adrian et al., 1998; Palanzo et al., 1999). In addition,, there is  limited data on the potential benefits of albumin in both on- and off-pump cardiac surgery; albumin was shown to be superior to crystalloids as a ‘pump-priming’ solution in on-pump cardiac surgery (Russell et al., 2004), and a reduction in bleeding in comparison to hydroxyethyl starch solutions was observed in off-pump cardiac surgery (Wilkes et al., 2001; Lee et al., 2016). However, the safety of albumin is continually questioned as other studies on albumin use have reported anaphylactic reactions (Ring & Messmer, 1977; Stafford et al., 1988; Fujita et al., 2007), transmission of prion disease, and acute kidney injury (AKI) in patients with underlying kidney dysfunction (Frenette et al., 2014).

The Kingeter et al. retrospective study of adult patients who underwent cardiac surgery at 59 different institutions between 2001 and 2013 aimed to investigate the effect of fluid choice during CPB on patient outcomes. The analysis compared matched cohorts (n = 1,095) of patients (those treated with 5% albumin with crystalloids, and those treated with crystalloids alone) for all-cause in-hospital mortality, AKI severity (Acute Kidney Injury Network [AKIN] classification), major morbidity (composite), and all-cause 30-day readmissions (figure 1).

Summary of a retrospective study of fluid choice and cardiac surgery patient outcomes.

Figure 1. Summary of a retrospective study of fluid choice and cardiac surgery patient outcomes. OR, odds ratio; CI, confidence interval; AKI, acute kidney injury (Kingeter et al., 2018).

Life after cardiac surgery: long-term fluid therapy insights

Cardiac surgery remains a high-risk procedure and measures should be taken to improve patient outcomes. The current study offers interesting insights into the much-debated topic of fluid therapy and patient safety. Despite past criticism of albumin safety, 5% albumin was shown to decrease mortality risk compared to crystalloids in this cohort of patients (figure 1). However, the authors of this study do not infer a causal link between 5% albumin and improved survival in on-pump cardiac surgery because of the absence of randomised clinical trials and study limitations.

Another positive outcome observed, which may have financial benefits for the treating hospital, was lower rates of 30-day readmissions in the 5% albumin group (figure 1). The mechanisms behind these positive effects of 5% albumin remain unknown and require further investigation. However, having a favourable sequential organ failure (SOFA) pulmonary score has been suggested as a possible indicator for success (albumin 44.9% vs. crystalloid 67%, p<0.01).  

Interestingly, previous safety concerns surrounding albumin use and increased risk of AKI weren’t reflected in the Kingeter et al. study as similar frequencies of AKI/AKIN stage 1–3 were seen in both treatment groups (figure 1). However, the analysis of AKI severity was limited to matched pairs from each treatment arm that had both baseline and preoperative serum creatinine (SCr) measurements (n = 517 in each arm), which may have underestimated the frequency. In addition, composite major morbidity, formed of 15 exploratory outcomes, didn’t appear to be associated with 5% albumin administration (figure 1).

While this study has captured valuable insights into surgical outcomes over a 12-year period, further studies are required to fully investigate the potential benefits of 5% albumin in cardiac surgery patients. Future randomised control trials should include sample size estimates based on expected pulmonary dysfunction differences and rates of large haemoglobin drop, as these were also lower among patients treated with albumin.

 

References

Adrian K, Mellgren K, Skogby M, Friberg LG, Mellgren G, Wadenvik H. The effect of albumin priming solution on platelet activation during experimental long-term perfusion. Perfusion. 1998;13:187–91.

Bruschi M, Candiano G, Santucci L, Ghiggeri GM. Oxidized albumin. The long way of a protein of uncertain function. Biochim Biophys Acta. 2013;1830:5473–9.

Fanali G, di Masi A, Trezza V, Marino M, Fasano M, Ascenzi P. Human serum albumin: from bench to bedside. Mol Aspects Med. 2012;33:209–90.

Frenette AJ, Bouchard J, Bernier P, Charbonneau A, Nguyen LT, Rioux JP, et al. Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis. Crit Care. 2014;18:602.

Fujita A, Kitayama M, Hirota K. Anaphylactoid shock in a patient following 5% human serum albumin infusion during off-pump coronary artery bypass grafting. J Anesth. 2007;21:396–8.

Jiang Y, Shaw AD. Albumin supplementation as a therapeutic strategy in cardiac surgery: useful tool or expensive hobby? Anesthesiology. 2016;124:983–5.

Kingeter AJ, Raghunathan K, Munson SH, Hayashida DK, Zhang X, Iyengar S, et al. Association between albumin administration and survival in cardiac surgery: a retrospective cohort study. Can J Anaesth. 2018. Epub ahead of print.

Lee EH, Kim WJ, Kim JY, Chin JH, Choi DK, Sim JY, et al. Effect of exogenous albumin on the incidence of postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass surgery with a preoperative albumin level of less than 4.0 g/dl. Anesthesiology. 2016;124:1001–11.

Ohqvist G, Settergren G, Bergström K, Lundberg S. Plasma colloid osmotic pressure during open-heart surgery using noncolloid or colloid priming solution in the extracorporeal circuit. Scand J Thorac Cardiovasc Surg. 1981a;15:251–5.

Ohqvist G, Settergren G, Lundberg S. Pulmonary oxygenation, central haemodynamics and glomerular filtration following cardiopulmonary bypass with colloid or non-colloid priming solution. Scand J Thorac Cardiovasc Surg. 1981b;15:257–62.

Palanzo DA, Zarro DL, Manley NJ, Montesano RM, Quinn M, Gustafson PA. Effect of surface coating on platelet count drop during cardiopulmonary bypass. Perfusion. 1999;14:195–200.

Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet. 1977;1:466–9.

Russell JA, Navickis RJ, Wilkes MM. Albumin versus crystalloid for pump priming in cardiac surgery: meta-analysis of controlled trials. J Cardiothorac Vasc Anesth. 2004;18:429–37.

Stafford CT, Lobel SA, Fruge BC, Moffitt JE, Hoff RG, Fadel HE. Anaphylaxis to human serum albumin. Ann Allergy. 1988;61:85–8.

Wilkes MM, Navickis RJ, Sibbald WJ. Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding. Ann Thorac Surg. 2001;72:527–33.

 

Publications (27)
  • Hydroxyethyl starch solutions and patient harm

    Following the European Medicines Agency’s (EMA) suspension of the marketing authorisations of hydroxyethyl starch (HES) solutions across the European Union (EMA, 2018), Roberts et al., have written an open letter addressed to the World Health Organization (WHO) Director General seeking support for the suspension of HES solutions and expanding it to a worldwide ban.

  • Recruitment of extravascular fluid by hyperoncotic albumin

    In 1896 Ernest Starling published his hypothesis for fluid exchange, whereby fluid exchange exists mainly in the capillaries through a process of plasma ultrafiltration across semipermeable membranes (Starling, 1896). But is this 19th century theory something of the past?

Login/ Register Maximise Minimise