This review article explores the relationship between low albumin levels and acute kidney injury (AKI). It reviews 43 relevant studies in several settings. There is only one randomised trial, and most are retrospective. There is a clear association between low albumin levels and the likelihood of developing AKI – yet there is no hard evidence for causation. The authors remark that the randomised trial demonstrated reduced AKI incidence with albumin administration, but acknowledge that much more quality research is needed to define the relationship.
AKI is a rapid deterioration of renal function that occurs rapidly, over hours or days, it involves a rising serum creatinine and a decreasing urine output. It is an acute systemic disease, yet one that has potentially significant consequences for other organs. In the short-term, it is associated with fluid, electrolyte and acid/base abnormalities; featuring rising levels of uraemic toxins, cytokines and systemic inflammation. In the longer term, it is associated with myocardial infarction, chronic kidney disease (CKD), increased mortality, the need for renal replacement and potentially transplantation. It is a common disorder, one that may be provoked by infection, acute glomerular disease, underlying CKD, trauma and haemorrhage or a number of iatrogenic causes. Hypoalbuminaemia (defined in different settings as either ≤3.5 g/dL or <3.5–4.0 g/dL), is an established risk factor for increased morbidity and mortality, and was previously identified as a significant independent predictor of AKI and death following AKI by the authors of this report. The purpose of this review was to explore data that has come to light subsequently.
A literature search was performed on the PubMed database (September 2009–December 2016 inclusive), data were extracted on the clinical setting, population, study design and size, assessment of albumin levels, occurrence of AKI and mortality. They identified 43 research articles: 37 of which were retrospective, five were prospective observational studies and one was a randomised controlled trial.
AKI is a common complication following cardiac surgery, and carries morbidity, mortality and economic costs. This review identified eight studies in this setting comprising around 4,000 participants.
This review identified several studies covering infectious diseases:
Hypoalbuminaemia is common before and after transplantation – particularly in liver cirrhosis.
An association between hypoalbuminaemia and AKI-related morbidity and mortality has also been noted.
There were 15 other studies that explored albumin and AKI in other settings. The largest (n=37,142) noted that in total knee replacement, mortality was higher in patients with low serum albumin (OR 3.17; 95% CI 1.56–6.35; p=0.001) as was risk of AKI (OR 5.19; 95% CI 1.96–13.37; p=0.001).
This review article goes through the recent evidence on AKI and albumin. The only study that clearly demonstrates something new is the RCT – suggesting a potential benefit for albumin administration in the cardiac surgery setting, albeit from a relatively small-scale study. Hypoalbuminaemia is potentially reflective of many disease states, from reduced liver function through to malnutrition or severe infection, and AKI may result from many of these same processes. It is possible that albumin is the common factor, however, despite a clear association between the two, much careful research is needed to define causation.
Catch-up on the debate surrounding hydroxyethyl starch use as we take you on an interactive journey through its changing fortunes. Do you think current restrictions will be enough to change clinical practice?
This position paper from the Italian Association for the Study of the Liver (AISF) and the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) reviews the evidence for the use of albumin in several settings related to liver cirrhosis.
This paper presents a meta-analysis to determine the impact of resuscitation with albumin on the morbidity and mortality of adult burn patients.
This meta-analysis examines whether the dosing of albumin affects outcomes in type 1 hepatorenal syndrome (HRS).
This review article explores the relationship between low albumin levels and acute kidney injury (AKI).
This meta-analysis pooled data from three large randomised controlled trials to determine whether early goal-directed therapy (EGDT) was an effective intervention for managing septic shock.
This systematic review and meta-analysis looked at the different mortality rates of various intravenous fluids and fluid protocols when used for resuscitation in sepsis.
This Chinese randomised controlled study explores the impact that a goal-directed fluid restriction (GDFR) protocol had on outcomes during anaesthesia for brain surgery.
This review paper examines the role of albumin in chronic liver disease, assessing the evidence for its use in several key clinical areas.
This matched cohort study aimed to determine whether a goal-directed fluid therapy (GDFT) intervention, delivered intraoperatively, would reduce post-operative morbidity in patients undergoing hip revision surgery.
This study explored fluid prescribing practices in intensive care – providing a picture of how fluid resuscitation is being managed internationally.
This multicentre audit reviewed the records of 431 patients who had undergone major elective surgery. The authors sought to determine how well IV fluids were prescribed both intraoperatively and perioperatively when compared with current guidance.
This double-blinded, randomised controlled trial examined whether pre-operative administration of exogenous albumin affected rates of acute kidney injury (AKI).
This article is a review and summary of the current opinion of albumin in fluid management.
This retrospective, observational study used a propensity scoring system to match patients treated with saline with those given a balanced, calcium-free fluid.
A recent PRAC review has recommended suspension of marketing authorisations for HES solutions for infusion across the EU.
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.
The Coordination Group for Mutual Recognition and Decentralised Procedures (CMDh) endorse the suspension of hydroxyethyl-starch (HES) solutions, due to serious risks of kidney injury and death in certain patient populations.
The hypothesis that hypertonic fluid has a dual physiological role, increasing circulatory volume while administering minimal volumes and muting the pro-inflammatory response to injury and illness, may be appealing, but is it superior to isotonic fluids in practice?
In this post-hoc, subgroup analysis (study 1) and prospective, single-centre nested cohort (study 2) from the SPLIT (0.9% saline vs. PL-148 for ICU fluid therapy) trial, the investigators hypothesised that patients receiving Plasma-Lyte 148 would require fewer blood products and have less post-operative bleeding than those receiving saline.
Acute kidney injury (AKI) affects one-fifth of major surgery patients, increasing the risk of long-term mortality. This review paper discusses recent study data, discussing the best methods for preventing postoperative AKI.
Guidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the supporting evidence is limited, and there is concern about impaired organ perfusion.
Cirrhosis of the liver is a leading cause of mortality. For patients with decompensated cirrhosis, long-term weekly human albumin administration can act as an effective disease-modifying treatment.
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?
Long-term albumin treatment for ascites associated with cirrhosis has been debated in recent years, with mixed results reported for the treatment’s efficacy. In this non-randomised prospective study, Di Pascoli and colleagues question the benefits of long-term albumin in patients with liver cirrhosis and refractory ascites, focussing on survival and emergent hospitalisations. Could this be part of the solution to the ongoing challenge of ascites in cirrhosis?
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.
Patients admitted to intensive care are often haemodynamically unstable with fluid resuscitation therapy regularly used to overcome this. The use of small volume resuscitation with 20% albumin has historically been limited compared to standard fluid resuscitation with 4–5% albumin due to safety concerns, but could those concerns be misplaced? Read more about how the SWIPE trial has provided new insights into the possibilities of using small volume resuscitation within the ICU.