Albumin Administration Research Articles

Long-term administration of human albumin improves survival in patients with cirrhosis and refractory ascites.

In patients with cirrhosis, the clinical benefit of the treatment with human albumin for ascites is debated, and no data are available regarding refractory ascites. In this study, in patients with cirrhosis and refractory ascites, we assessed the effect of long-term albumin administration on emergent hospitalization and mortality. Seventy patients with cirrhosis and refractory ascites, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, were included into the study. Forty-five patients were non-randomly assigned to receive long-term administration of human albumin at the doses of 20g twice per week (n=45), in addition to standard medical of care (SOC), and compared to those followed according to SOC. Patients were followed up to the end of the study, liver transplantation or death. The cumulative incidence of 24-month mortality was significantly lower in patients treated with albumin than in the group of patients treated with SOC (41.6% vs 65.5%; P=0.032). The period free of emergent hospitalization was significantly longer in patients treated with long-term administration of albumin (P=0.008). Analysing separately the causes of inpatient admission, patients treated with albumin showed a reduction in the incidence of overt hepatic encephalopathy, ascites, spontaneous bacterial peritonitis (SBP) and non-SBP infections. In addition, a non-significant trend towards a reduced probability of hepatorenal syndrome was observed. In patients with cirrhosis and refractory ascites, long-term treatment with albumin improves survival and reduces the probability of emergent hospitalizations.

Hepatorenal syndrome

Hepatorenal syndrome (HRS) is a form of kidney function impairment that characteristically occurs in cirrhosis. Recent changes in terminology have led to acute HRS beingreferred to as acute kidney injury (AKI)-HRS and chronic HRS as chronic kidney disease (CKD)-HRS. AKI-HRS is characterized by a severe impairment of kidney function owing to vasoconstriction of the renal arteries in the absence of substantial abnormalities in kidney histology. Pathogenetic mechanisms involve disturbances in circulatory function due to a marked splanchnic arterial vasodilation, which triggers the activation of vasoconstrictor factors. Anintense systemic inflammatory reaction that is characteristic of advanced cirrhosis may also be involved. The main triggering factors of AKI-HRS are bacterial infections, particularly spontaneous bacterial peritonitis. The diagnosis of AKI-HRS is a challenge because of a lack of specific diagnostic tools and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The prognosis of patients with AKI-HRS is poor, with a median survival of ≤3 months. The ideal treatment for AKI-HRS is liver transplantation in patients without contraindications. Medical therapy consists of vasoconstrictor drugs to counteract splanchnic arterial vasodilation together with volume expansion with albumin. Effective measures to prevent AKI-HRS include early identification and treatment of bacterial infections and the administration of albumin in patients with spontaneous bacterial peritonitis.

Albumin 5% Versus Crystalloids for Fluid Resuscitation in Children After Cardiac Surgery*

To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation in children admitted after cardiac surgery. Retrospective pre-/postintervention cohort study. Stollery Children's Hospital tertiary care pediatric cardiac ICU. Children admitted to the pediatric cardiac ICU after cardiac surgery. Fluid resuscitation policy change in which crystalloids replaced albumin 5% as the primary fluid strategy for resuscitation after cardiac surgery. Children who underwent cardiac surgery in the 6 months prior to the policy change (5% albumin group) were compared with children admitted during the 6 months after (crystalloid group). Demographic, perioperative, and outcome variables (fluid intake days 1-4 postoperative, vasoactive therapy, blood products, time to negative fluid balance, renal replacement therapies, mechanical ventilation, pediatric cardiac ICU, and length of stay) were collected. Data were analyzed using linear and logistic multivariate analysis. The study included 360 children. There was no association between fluid group and fluid intake (mL/kg) on day 1 postoperatively (coefficient, 2.84; 95% CI, 5.37-11.05; p = 0.497). However, crystalloid group was associated with significantly less fluid intake on day 2 (coefficient, -12.8; 95% CI, -22.0 to -3.65; p = 0.006), day 3 (coefficient, -14.9; 95% CI, -24.3 to -5.57; p = 0.002), and on the first 48 hours postoperative (coefficient, 10.1; 95% CI, -27.9 to -1.29; p = 0.032). Pediatric cardiac ICU stay (coefficient, -1.29; 95% CI, -2.50 to -0.08; p = 0.036) was shorter for the crystalloid group. There were no significant differences in the time to negative balance, need for renal replacement therapy, mechanical ventilation days, hospital stay, or pediatric cardiac ICU survival. In our study, the use of albumin 5% for resuscitation after cardiac surgery was not associated with less fluid intake but rather the opposite. Albumin administration did not provide measured clinical benefit while exposing children to side effects and generating higher costs to the healthcare system.

Development and in vivo evaluation of chitosan nanoparticles for the oral delivery of albumin

Albumin is used as a plasma expander in critically ill patients and for several other clinical applications mainly via intravenous infusion. Oral administration of albumin can improve patient compliance although limited oral bioavailability of proteins is still a major challenge. Although nanomaterials have been extensively utilized for improving oral delivery of proteins, albumin has been utilized only as either a model drug or as a carrier for drug delivery. In the current study, for the first time, chitosan nanoparticles have been developed and extensively optimized to improve oral bioavailability of albumin as a therapeutic protein. Several characterizations have been performed for the albumin-loaded nanoparticles (e.g. drug encapsulation efficiency, DSC, FTIR, particle size, zeta potential, morphology, release kinetics, and enzymatic stability). Nanosized spherical particles were prepared and demonstrated high stability over three months either in a powdered form or as suspensions. Sustained release of albumin over time and high enzymatic stability as compared to the free albumin were observed. In vivo, higher serum concentrations of albumin in normal rabbits and cirrhotic rats were attained following oral and intraperitoneal administrations of the albumin-loaded nanoparticles as compared to the free albumin. The nanoparticles developed in the current study might provide efficient nanovehicles for oral administration of therapeutic albumin.

Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial

Evidence is scarce on the efficacy of long-term human albumin (HA) administration in patients with decompensated cirrhosis. The human Albumin for the treatmeNt of aScites in patients With hEpatic ciRrhosis (ANSWER) study was designed to clarify this issue. We did an investigator-initiated multicentre randomised, parallel, open-label, pragmatic trial in 33 academic and non-academic Italian hospitals. We randomly assigned patients with cirrhosis and uncomplicated ascites who were treated with anti-aldosteronic drugs (≥200 mg/day) and furosemide (≥25 mg/day) to receive either standard medical treatment (SMT) or SMT plus HA (40 g twice weekly for 2 weeks, and then 40 g weekly) for up to 18 months. The primary endpoint was 18-month mortality, evaluated as difference of events and analysis of survival time in patients included in the modified intention-to-treat and per-protocol populations. This study is registered with EudraCT, number 2008-000625-19, and ClinicalTrials.gov, number NCT01288794. From April 2, 2011, to May 27, 2015, 440 patients were randomly assigned and 431 were included in the modified intention-to-treat analysis. 38 of 218 patients died in the SMT plus HA group and 46 of 213 in the SMT group. Overall 18-month survival was significantly higher in the SMT plus HA than in the SMT group (Kaplan-Meier estimates 77% vs 66%; p=0·028), resulting in a 38% reduction in the mortality hazard ratio (0·62 [95% CI 0·40-0·95]). 46 (22%) patients in the SMT group and 49 (22%) in the SMT plus HA group had grade 3-4 non-liver related adverse events. In this trial, long-term HA administration prolongs overall survival and might act as a disease modifying treatment in patients with decompensated cirrhosis. Italian Medicine Agency.

Effects of Periostracum Cicadae on Cytokines and Apoptosis Regulatory Proteins in an IgA Nephropathy Rat Model.

Periostracum cicadae, the cast-off shell of the cicada Cryptotympana pustulata Fabricius, is used in traditional Chinese medicine for its diaphoretic, anticonvulsive, sedative, antipyretic, and antiallergic effects. However, the exact pathogenesis of immunoglobulin A nephropathy (IgAN) remains unclear, thereby hindering investigations to identify novel therapeutic agents. A rat IgAN model was established by administration of bovine serum albumin, lipopolysaccharide, and carbon tetrachloride, which simultaneously established blood stasis and a heat syndrome model. The animals were sacrificed to detect changes in protein levels in urine and blood. Immunofluorescence was performed to assess IgA deposition in the glomeruli. Tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin 6 (IL-6) levels were measured in bronchoalveolar lavage fluid (BALF) by enzyme-linked immunosorbent assay. Hematology and eosin, periodic acid-Schiff, TUNEL (TdT-mediated dUTP Nick-End Labeling), and immunohistochemical staining were performed to evaluate histopathological changes in kidney tissues. Additionally, target-related proteins were measured by Western blotting. Periostracum cicadae resulted in a reduction in blood and urine protein levels. Serum TNF-α, IL-1β, and IL-6 levels significantly decreased in the periostracum cicadae-treated groups compared to the IgAN group. Furthermore, a reduction in MCP-1 (Monocyte Chemotactic Protein-1), TLR4 ((Toll-Like Receptor 4)), and IgA expression levels and a dose-dependent increase in caspase 3 expression were observed in response to periostracum cicadae treatment. TGF-β1(Transforming Growth Factor-β) levels decreased, whereas that of Fas increased in the kidney tissues of the periostracum cicadae-treated groups. The findings of the present study indicate that periostracum cicadae induces apoptosis and improves kidney inflammation and fibrosis in IgA nephropathy rat models.

Diagnostic criteria of hepatorenal syndrome and modern methods of therapy (literature review)

Hepatorenal syndrome (HRS) is a variant of functional renal failure in acute or chronic liver pathology. Type 1 HRS entails a rapidly progressive decline in kidney function within few days and without liver transplantation, 95,0 % of patients die within the next few weeks. With type 2 HRS, kidney function remains stable or gradually declining over several months. HRS diagnosis is based on the exclusion of other causes of renal failure. Pathophysiological changes in renal failure in the case of HRS are quite complex – they include an increase in the synthesis of vasoactive substances, which lead to a decrease in renal perfusion, a decrease in resistance in peripheral arteriovenous anastomosis, the development of portal hypertension, ascites, a decrease in colloidal osmotic pressure and a consistently increasing delay of sodium and water in the kidneys. HRS therapy is based on acid-base balance and anemia correction, intravenous administration of albumin, paracentesis, the removal of nephrotoxic agents and the renal replacement therapy is only symptomatic. areast-font-family:Times New Roman;mso-bidi-font-family:Times New Roman; mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA'>, 420012

Fluid therapy and shock: an integrative literature review.

shock refers to a physiological situation that puts life at risk. Its early identification and the timely institution of therapeutic measures can avoid death. Despite the frequent administration of fluid therapy as a treatment for shock, the type and dose of fluids to be delivered remain undetermined. to determine the type of fluids to be administered and the type of approach to be performed in the different types of shock. integrative literature review. data about fluid therapy in hypovolaemic and distributive shock were obtained, specifically in the haemorrhagic and the septic types. None of the articles addressed cardiogenic shock. hypotensive resuscitation, with blood, is the most appropriate approach in haemorrhagic shock. There remains a question regarding the best approach in septic shock. However, conservative fluid therapy seems to be appropriate, with preference given to the administration of balanced crystalloids or albumin as an alternative.

Antigen-specific airway IL-33 production depends on FcγR-mediated incorporation of the antigen by alveolar macrophages in sensitized mice.

Although interleukin (IL)-33 is a candidate for the aggravation of asthma, the mechanisms underlying antigen-specific IL-33 production in the lung are unclear. Therefore, we analysed the mechanisms in mice. Intra-tracheal administration of ovalbumin (OVA) evoked increases in IL-33 and IL-33 mRNA in the lungs of both non-sensitized and OVA-sensitized mice, and the increases in the sensitized mice were significantly higher than in the non-sensitized mice. However, intra-tracheal administration of bovine serum albumin did not increase the IL-33 level in the OVA-sensitized mice. Depletion of neither mast cells/basophils nor CD4+ cells abolished the OVA-induced IL-33 production in sensitized mice, suggesting that the antigen recognition leading to the IL-33 production was not related with either antigen-specific IgE-bearing mast cells/basophils or memory CD4+ Th2 cells. When a fluorogenic substrate-labelled OVA (DQ-OVA) was intra-tracheally administered, the lung cells of sensitized mice incorporated more DQ-OVA than those of non-sensitized mice. The lung cells incorporating DQ-OVA included B-cells and alveolar macrophages. The allergic IL-33 production was significantly reduced by treatment with anti-FcγRII/III mAb. Depletion of alveolar macrophages by clodronate liposomes significantly suppressed the allergic IL-33 production, whereas depletion of B-cells by anti-CD20 mAb did not. These results suggest that the administered OVA in the lung bound antigen-specific IgG Ab, and then alveolar macrophages incorporated the immune complex through FcγRII/III on the cell surface, resulting in IL-33 production in sensitized mice. The mechanisms underlying the antigen-specific IL-33 production may aid in development of new pharmacotherapies.

The use of human albumin in patients with cirrhosis: a European survey

ABSTRACTBackground: The administration of human albumin (HA) in patients with decompensated cirrhosis is still debated. The European Foundation for the Study of Chronic Liver Failure (EF-CLIF) promoted an online survey to assess its use across Europe.Methods: Hepatologists were invited to participate to an electronic questionnaire based on multiple-choice questions divided in 6 different areas. A descriptive statistical analysis was performed to analyze the responses.Results: One hundred-one hepatologists (36% non-EF-CLIF member), belonging to 86 centers (25% non-academic hospitals) completed the survey. The vast majority of participants prescribe HA for the evidence-based indications supported by international guidelines, while a proportion of them consider HA administration useful for other complications currently not supported by solid scientific evidence. Participants show a good level of knowledge about the non-oncotic properties of the molecule, while HA prescription does not appear to be restricted by health authorities in most centers, at least for the evidence-based indications.Conclusions: The present survey indicates that hepatologists across Europe present adherence to international guidelines and highlights the areas where solid scientific data are awaited to achieve a more appropriate HA prescription in patients with decompensated cirrhosis.

THU-277 - Albumin administration in the prevention of hepatorenal syndrome (HRS) and death in patients with advanced cirrhosis and non-SBP infections

THU-277 - Albumin administration in the prevention of hepatorenal syndrome (HRS) and death in patients with advanced cirrhosis and non-SBP infections

Albumin induces CD44 expression in glomerular parietal epithelial cells by activating the ERK signaling pathway

De novo expression of CD44 in glomerular parietal epithelial cells (PECs) leads to a pro‐sclerotic and migratory PEC phenotype in focal segmental glomerulosclerosis. However, the mechanisms underlying CD44 induction in activated PECs remain largely unknown. This study was performed to examine CD44 expression in rat PECs under proteinuric condition and its regulatory mechanisms. CD44 gene and protein levels were examined in Zucker diabetic (ZD) rat kidneys and primary cultured rat PECs exposed to exogenous albumin. Gene microarray and real‐time PCR confirmed an upregulation of CD44 mRNA in renal cortex and glomeruli of ZD rats. Immunofluorescence staining of kidney sections revealed an increase in CD44 signal in claudin‐1‐positive PECs. Enhanced CD44 staining was observed in activated PECs localized in Bowman's capsule and migrated into the glomerular tuft. Moreover, anti‐proteinuric treatment with losartan, an angiotensin II receptor blocker, significantly reduced CD44 protein level in the diabetic rat kidney. In primary cultured rat PECs, administration of rat serum albumin (RSA, 0.25 – 1 mg/ml) resulted in an activation of ERK1/2 MAPK signaling and upregulation of CD44 and claudin‐1 protein expression. This increase in claudin‐1 and CD44 protein was significantly attenuated in the presence of specific ERK1/2 inhibitor U0126. Taken together, our results demonstrate that albumin activates PECs and induces CD44 expression, at least partially via the activation of ERK signaling pathway.Support or Funding InformationNIH SC1DK112151, NIH/NCRR/RCMI 8G12MD007602 & 8U54MD007588This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

PS-076 - Long-term administration of human albumin reduces hospitalization and improves survival in patients with cirrhosis and refractory ascites

PS-076 - Long-term administration of human albumin reduces hospitalization and improves survival in patients with cirrhosis and refractory ascites

EPTFE‐TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis

Reduction in portal pressure by self-expandable polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts (TIPS) is a treatment option for refractory ascites. Data on clinical outcomes after ePTFE-TIPS vs repetitive large-volume paracentesis (LVP) plus albumin (A) administration for the treatment of patients with refractory ascites are limited. Retrospective comparison of ePTFE-TIPS vs LVP+A in terms of (i) control of ascites, (ii) occurrence of overt hepatic encephalopathy (HE) and (iii) transplant-free survival in cirrhotic patients with refractory ascites. Among n=221 patients with cirrhosis and refractory ascites, n=140 received ePTFE-TIPS and were compared to n=71 patients undergoing repetitive LVP+A. After ePTFE-TIPS, ascites was controlled without any further need for paracentesis in n=76 (54%; n=7 without and n=69 with diuretics). The need for frequent large-volume paracentesis was significantly higher in the LVP+A group than with ePTFE-TIPS (median 0.67 (IQR: 0.23-2.63) months vs 49.5 (IQR: 5.07-102.60) months until paracentesis, log-rank P<.001). De-novo incidence of HE was similar in ePTFE-TIPS and LVP+A patients (log-rank P=.361). Implantation of ePTFE-TIPS was associated with improved 1-year survival as compared to LVP+A (65.6% vs 48.4%, log-rank P=.033). Age (odds ratio (OR):1.05; 95% confidence interval (95% CI):1.03-1.07; P<.001), serum albumin (OR: 0.95; 95% CI: 0.92-0.99; P=.013) and hepatocellular carcinoma (OR: 1.66; 95% CI: 1.06-2.58; P=.026) emerged as independent predictors of survival. ePTFE-TIPS results in superior control of ascites without increasing the risk for overt HE as compared to LVP+A. Although ePTFE-TIPS improved 1-year survival in cirrhotic patients with refractory ascites, its use was not independently associated with transplant-free survival.

Prognostic Value of Secretoneurin in Patients With Severe Sepsis and Septic Shock: Data From the Albumin Italian Outcome Sepsis Study.

Secretoneurin directly influences cardiomyocyte calcium handling, and circulating secretoneurin levels seem to improve risk prediction in patients with myocardial dysfunction by integrating information on systemic stress, myocardial function, and renal function. Accordingly, in this study, we hypothesized that secretoneurin would improve risk prediction in patients with sepsis and especially in patients with septic shock as these patients are more hemodynamically unstable. Multicenter, interventional randomized clinical trial. Multicenter, pragmatic, open-label, randomized, prospective clinical trial testing fluid administration with either 20% human albumin and crystalloids or crystalloid solutions alone in patients with severe sepsis or septic shock (The Albumin Italian Outcome Sepsis). In total, 540 patients with septic shock and 418 patients with severe sepsis. Either 20% human albumin and crystalloids or crystalloid solutions alone. We measured secretoneurin on days 1, 2, and 7 after randomization and compared the prognostic value of secretoneurin for ICU and 90-day mortality with established risk indices and cardiac biomarkers in septic shock and severe sepsis. High secretoneurin levels on day 1 were associated with age and serum concentrations of lactate, bilirubin, creatinine, and N-terminal pro-B-type natriuretic peptide. Adjusting for established risk factors and cardiovascular biomarkers, secretoneurin levels on day 1 were associated with ICU (odds ratio, 2.27 [95% CI, 1.05-4.93]; p = 0.04) and 90-day mortality (2.04 [1.02-4.10]; p = 0.04) in patients with septic shock, but not severe sepsis without shock. Secretoneurin levels on day 2 were also associated with ICU (3.11 [1.34-7.20]; p = 0.008) and 90-day mortality (2.69 [1.26-5.78]; p = 0.01) in multivariate regression analyses and improved reclassification in patients with septic shock, as assessed by the net reclassification index. Randomized albumin administration did not influence the associations between secretoneurin and outcomes. Secretoneurin provides early and potent prognostic information in septic patients with cardiovascular instability.

Albumin Utilization Evaluation in a Major Teaching Hospital in Iran: Recommendations for Guideline Development.

Objective:Human albumin solution is an expensive colloidal preparation which is commonly used in clinical practice. Due to high cost of albumin, increased rate of the inappropriate use worldwide, and many other reasons, it is imperative to establish a practical protocol to use albumin products and limit its usage. The aim of this study was to identify albumin utilization patterns in a teaching hospital and to demonstrate the importance of the need to reconsider prescribing strategies for albumin administration.Methods:This retrospective cross-sectional study was performed between August 2016 and December 2016 at Firoozgar Hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. All albumin prescriptions for adult patients during the study period were enrolled for appropriateness evaluation according to the latest evidence-based studies and guidelines.Findings:Among 320 albumin prescriptions, 168 (52.5%) were inappropriate according to the current evidence. The most common irrational causes for the albumin usage were hypoalbuminemia (23.4%), nutritional support (13.7%), neuroprotection in subarachnoid hemorrhage (3%), pretreatment for cancer surgery (2.8%), edema (1.6%), hepatic failure (1.6%), and paracentesis (3%). The total amount of albumin used for 320 patients was 52,050 g, from which 28,470 g was inappropriate resulting in $97,398 wastage.Conclusion:These findings, along with aforementioned guidelines, support the requirement for physicians' educational programs and proper strategies for appropriate prescriptions and could also be important in modifying the available guidelines concerning expensive drugs such as albumin.

A Case Study on Ascites of Hepatic Origin and Their Proper Management in a Male German Shepherd Dog

A male German shepherd dog of 11 months was presented to HART Clinic, Pokhara with the history of abdominal swelling, respiratory distress, lethargy, anorexia and weakness. Physical examination revealed dyspnea, pale mucous membrane, and undulating movement (thrills) of fluid on tapping the abdomen. Fecal sample collected for assessing the severity of endoparasites which was found negative. The hematological study showed an increase in numbers of neutrophils, while there were decreased erythrocytes and hemoglobin concentration. The biochemical analysis resulted in an elevated SGOT, SGPT level but decrease in total protein level. Ascitic fluid collected from abdominal paracentesis on examination revealed transudate fluid with serum-albumin ascetic gradient (SAAG) &gt;1.1 gm/dl suggesting ascites due to portal hypertension (96% accuracy) caused by Liver cirrhosis. The dog was diagnosed as ascites of hepatic origin resulting portal hypertension and hypoproteinemia. The abdominocentesis was performed to drain the ascetic fluid followed by albumin and normal saline administration. The dog was further treated with antibiotic, diuretic, amino acid and liver tonics along with protein rich but salt free diet. The dog showed remarkable improvement with gradual reduced in abdominal distention and normalization of the appetite after 7 days of treatment.Int. J. Appl. Sci. Biotechnol. Vol 5(4): 555-558

Immediate Reduction in Hospital Pharmacy Costs with Intraoperative Restriction of Albumin Administration

Immediate Reduction in Hospital Pharmacy Costs with Intraoperative Restriction of Albumin Administration

The predictive performances of equations used to estimate unbound phenytoin concentrations in a medical ICU population and the impact of exogenous albumin administration

PurposeThis study evaluated the predictive performances of four equations (Sheiner-Tozer [ST], Kane-modified ST, Anderson-modified ST, and Cheng-modified ST) used to estimate free phenytoin concentrations in a medical intensive care unit (MICU) and assessed the impact of exogenously administered albumin. MethodsThirty MICU subjects receiving phenytoin were retrospectively evaluated. Predictive performances were assessed by mean absolute error (MAE), mean prediction error (MPE), and root mean squared error (RMSE); linear regression of predicted vs. actual unbound concentrations; and Bland-Altman plots. Parameters were further delineated by recent exogenous albumin administration. ResultsThe measured unbound phenytoin concentration was 2.14±0.84μg/mL for all 90 levels, 1.89±0.92μg/mL for the 58 levels without albumin, and 2.58±0.83μg/mL (p<0.0001 vs. without albumin) for the 32 levels after exogenous albumin. R2 values were below 0.4 for all equations. The ST equation over-predicted unbound concentrations whereas all other equations under-estimated unbound concentrations. All equations possessed bias and lacked precision. Bland-Altman plots demonstrated greatest bias with the ST equation. Albumin administration introduced additional bias, limited precision, reduced R2 values, and completely negated the performances of the ST and Kane-modified ST equations. ConclusionEstimating unbound concentrations with equations in the MICU population is discouraged.

Decompensated Cirrhosis and Fluid Resuscitation.

The critically ill patient with decompensated cirrhosis has a unique physiology and alterations in albumin that need to be understood to properly resuscitate them and minimize morbidity and mortality. Little data exist on specific resuscitation of the patient with cirrhosis compared with those patients without liver disease. The effectiveness of albumin administration compared with saline administration in common settings, such as large-volume paracentesis, can be extrapolated to the care of the general surgical patient but further studies in this area are warranted. This article enhances the understanding of unique physiology of the patient with decompensated cirrhosis to guide their needs in fluid resuscitation in critical illness.