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Human albumin: ICU


Human albumin: benefits in the intensive care unit


To fully understand whether human albumin might be beneficial in the ICU, specific categories of patient who may benefit from this treatment need to be determined. Here, the physiological rationale and the available clinical evidence behind this are discussed


Pietro Caironi MD Dipartimento di Fisiopatologia Medico- Chirurgica e dei Trapianti and Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico; Università degli Studi di Milano, Italy E-mail: pietro.caironi@unimi.it


The administration of human albumin as a clinical treatment implemented in critically ill patients has been much debated in the past 15 years.1 Despite the undeniable importance of this molecule in human physiology, the publication in 1998 of a large meta- analysis by the Cochrane Injuries Group Albumin Reviewers2


highlighted a 14


possible increased risk of death, even in categories of patients historically considered as therapeutic targets of this treatment. Unfortunately, the subsequent research on this topic did not yield clarification, and scarcely led to evidence-based recommendations.3,4 There are two likely reasons for such uncertainty: first, the excessive emphasis on meta-analyses as a tool to achieve high-quality evidence, in association with the lack of well-designed randomised, controlled trials (RCTs); and second, the great heterogeneity characterising critically ill patients. Thus, to fully understand whether human albumin may be beneficial in ICU, the right strategy would be to determine specific categories of patient who may benefit from this treatment, based upon a robust physiological rationale and solid clinical evidence, and individualise its application. This


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"Human albumin is responsible for about 80% of the intravascular oncotic pressure, thereby assuming a critical role in processes regulating the maintenance and fluid exchanges involving the blood compartment"


approach is crucial, in terms of efficacy (favourable balance between beneficial and detrimental effects), as well as in terms of costs (favourable balance between benefits and costs). It is therefore worthwhile summarising the physiological rationale and the available clinical evidence supporting the potential benefit or harm of using human albumin in critically ill patients.


Physiological role


In human physiology, albumin is a molecule having many crucial functions.1 In healthy conditions, the liver, under


the stimulation of the neuroendocrine system and the intravascular oncotic pressure, employs about 50% of its energy expenditure for the synthesis and the secretion of 10–12 grams/day albumin. Moreover, although mainly located within the intravascular compartment, albumin may pass at various degrees into the interstitial space, through a partially receptor- mediated process named 'transcapillary escape rate'.


As a primary function, human albumin is responsible for about 80% of the intravascular oncotic pressure, thereby


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