Intravenous Albumin Research Articles

Indications for chronic albumin infusion

While transjugular intrahepatic portosystemic shunt (TIPS) is a common therapy for cirrhotic patients with diuretic-resistant or diuretic-refractory ascites, some patients are unsuitable for the procedure for technical or medical reasons. We report our experience with the use of chronic intravenous albumin infusions to achieve diuresis in this difficult patient population and review the historic experience of chronic albumin infusions as a treatment for ascites. Nineteen patients with cirrhosis and diuretic-resistant or diuretic-refractory ascites who were deemed unsuitable for TIPS received outpatient intravenous albumin infusions (50 g) weekly for at least 4 weeks. The following endpoints were retrospectively recorded: serum sodium, serum creatinine, blood urea nitrogen, hematocrit, bilirubin, albumin, international normalized ratio, body weight, and Model for End-stage Liver Disease (MELD) score. The contraindications for TIPS included the following: portal vein thrombosis, two; advanced age, one; encephalopathy, nine; hyperbilirubinemia, five; and other, two. Compared to pretreatment, posttreatment weight decreased in 17 patients, remained unchanged in 0 patients, and increased in 2 patients. The overall mean change in body weight (before vs. after therapy) was 8 lb (P < 0.05). The only significant change in biochemistries was an increase in serum albumin from 2.5 g/dl before therapy to 3.5 g/dl after therapy (P < 0.05). We conclude that (1) recurrent intravenous weekly albumin infusions resulted in significant loss of edema and ascites as measured by loss of body weight, and (2) clinicians may want to consider chronic albumin infusions for selected patients with refractory ascites who are not candidates for TIPS.

An Evaluation of Nutrition Support for Terminal Cancer Patients at Teaching Hospitals in Korea

We wanted to analyze the use of nutrition support for terminal cancer patients, the effect of discussing withdrawal of nutrition support and do-not-resuscitate (DNR) consent on the use of intravenous nutrition during the patient's last week of life and at the time of death. The study involved 362 patients with terminal cancer from four teaching hospitals, and they all died between January 1 2003 and December 31 2005. The basic demographic data, the use of intravenous nutrition during the patient's last week of life and at death, discussion of terminal nutrition withdrawal and DNR consent were evaluated. In the week before death, the patients received artificial nutrition such as total parenteral nutrition (31%), intravenous albumin infusion (25%), and feeding tube placements (9%). A discussion concerning withdrawal of nutrition support was limited to 25 (7%) patients. DNR consent was obtained from 294 (81%) patients. None of the patients were directly involved in any of these decisions. The discussion about withdrawal of terminal nutrition and DNR consent with the patient's surrogates did not have any effect on reducing the use of parenteral nutrition. The majority of patients dying of terminal cancer were still given potentially futile nutritional support. Modern clinical guidelines and ethical education about nutritional support at the end of life care is urgently needed in Korean medical practice to provide proper administration of terminal nutrition for end of life care.

Reticulo-endothelial function in obstructive jaundice.

A study of reticulo-endothelial function was performed in 30 patients with obstructive jaundice. Reticulo-endothelial phagocytic function, measured by the clearance of intravenous human micro-aggregated albumin, was significantly depressed in jaundiced patients compared with non-jaundiced controls (P less than 0.001). There was a significant correlation (P less than 0.001) between phagocytic function and plasma bilirubin level but not with transaminase or bile salt level. Phagocytic function was not related to the presence of malignancy, but was markedly reduced in patients with cholangitis. There was no reduction in hepatic sinusoidal blood flow, opsonin levels (fibronectin, IgG, complement) or serum opsonic activity to account for the reticulo-endothelial dysfunction.

Clinical course of congenital nephrotic syndrome and Denys‐Drash syndrome in Japan

The prognosis of Japanese patients with congenital nephrotic syndrome (CNS) and Denys-Drash syndrome (DDS) is not clear. Five patients with CNS and four patients with DDS, which causes secondary CNS, were studied retrospectively. Seven patients were sporadic and two DDS patients were identical twins. Five CNS patients presented with edema within 3 months of birth. In four DDS patients, edema was not noted and end-stage renal disease developed between 7 months and 6 years of age. Of these five CNS patients, one patient had cerebral thrombosis and cytomegalovirus pneumonia at the onset and another patient died during dialysis. Frequent intravenous albumin administration required, growth and development during infancy were varied. Of the nine patients with CNS and DDS, seven received renal transplantation and were alive with functioning grafts at the last follow up. Catch-up growth was observed in five patients after transplantation. Five school-aged patients attended school and received adequate grades and two adults worked full-time. Of the DDS patients, dysuria due to hypospadias persisted in one patient and treatment for hypogonadism was needed in one patient. CNS and DDS were diagnosed early after onset and adequate treatment was started. Growth and development after renal transplantation were relatively good. Thrombotic episodes or severe infection in CNS patients was difficult to manage and complications resulting from DDS affected the quality of life.

Comparative pilot study of repeated large volume paracentesis vs the combination on clonidine-spironolactone in the treatment of cirrhosis-associated refractory ascites

To study the usefulness of the combination of clonidine--spironolactone in refractory ascites. Twenty cirrhotic patients with refractory ascites were randomly assigned to receive repeated large volume paracentesis plus intravenous albumin (group 1), or a combination of clonidine (0.075 mg twice daily) and spironolactone (200 to 400 mg daily) (group 2). During the first hospitalisation,, the mean weight loss in group 1 was higher than in group 2 (12.4 +/- 3.2 versus 4.3 +/- 1.1 kg, P < or = 0.01). Mean stay in hospital was shorter in group 2 (20 +/- 1.5 versus 10 +/- 2.8 days; P < or = 0.01). Paracentesis did not induce changes in neuro-hormonal measurements. Oppositely, clonidine induced a decreased sympathetic activity, an increased glomerular filtration rate and a delayed reduction of the renin-aldosterone levels. During the follow-up in group 1, the number of rehospitalisations for ascites was higher than in group 2 (37 versus 3; P < or = 0.01), and the mean time to the first readmission was shorter (10 +/- 2.7 versus 23.7 +/- 5.6 days; P < or = 0.01). The total duration spent in hospital were similar in both groups. Paracentesis is more effective for short-term treatment of ascites but clonidine-spironolactone association might provide better long-term control.

A Randomized Prospective Placebo-Controlled Study of Intravenous albumin vs. Hydroxyethyl Starch for the Prevention of Ovarian Hyperstimulation in an In-Vitro Fertilization Programme

A prospective, randomized placebo-controlled study was conducted to assess the effectiveness of i.v. administration of 6% hydroxy ethyl starch(HES) solution versus intra venous albumin in preventing moderate and severe ovarian hyperstimulation(OHSS) in 320 patients (cycles) considered to have risk of OHSS in an IVF programme. Prospective randomized placebo controlled study Three hundred twenty women who had serum estradial value of more than 3000pg/ml and/or more than 20 follicles(14mm) on the day of human chorionic gonadotropin (hCG) administration were recruited into three groups: HES group (n=112) received 500ml(Isohes, Eczacibasi/ Baxter, Turkey) 6% HES; albumin group(n=105) received 20% human albumin 50 ml(10g)(Albumin Human, Octopharma /Berk, Turkey); and the placebo group(n=103) received 500 ml of sodium chloride 0.9% solution, infused over a period of 30 min immediately after oocyte retrieval. Three groups had similar demographic characteristics such as age, estradol level on hCG day, body mass index , number of oocytes retrieved, number of embryos transferred, duration of coasting (p>0.05). Severe OHSS was not observed in any of the patients of the HES or albumin groups, while six patients of the placebo group developed severe OHSS. Moderate OHSS was encountered in eight patients in the HES group; seven patients in the albumin group, 18 patients receiving placebo. Moderate OHSS incidence was found to be significantly higher in the placebo group compared to the HES and albumin groups(P values of <0.06, <0.05 and <0.01, respectively). Administration of HES and albumin may prevent the development of moderate-severe OHSS in high risk patients. HES solution appears to be an effective and cheaper alternative in reducing severe and OHSS during IVF treatment.

A Simple and Ambulatory Approach for Prevention and Treatment of Ovarian Hyperestimulation Syndrome

Ovarian hyper stimulation syndrome (OHSS) is a potentially serious and often uncomfortable complication during controlled ovarian hyperstimulation for IVF or Intracytoplasmatic sperm inyection (ICSI). Different strategies have been described for its prevention including coasting of stimulation treatment, reduced hCG administration, early follicular aspiration, the use of intravenous albumin, glucocorticoids, cancellation of embryo transfer and freezing. The objective of this presentation is to communicate the approach used to treat OHSS in our clinic.

Intravenous Albumin Prophylaxis in High Risk Patients for Moderate to Severe Ovarian Hyperstimulation Syndrome

Intravenous albumin infusion during oocyte pick-up for the prevention of moderate to severe ovarian hyperstimulation syndrome (OHSS) at high risk patients, is still controversial. It was aimed to demonstrate the possible preventive effect of albumin administration during oocyte retrieval.

Long‐term clinical outcome of large volume paracentesis with intravenous albumin in patients with spontaneous bacterial peritonitis: A randomized prospective study

Large volume paracentesis (LVP) with plasma volume expansion has been used for tense or refractory ascites. However, still in question is whether it is safe and effective for the treatment of spontaneous bacterial peritonitis (SBP). We addressed this issue and conducted a study to assess safety and long-term outcome of LVP in cirrhotic patients with SBP. Forty-two randomly assigned cirrhotic patients with SBP were classified into two groups; Group 1 included 21 patients who were treated with LVP and intravenous albumin; and Group 2 included 21 patients who were treated with diuretics and intravenous albumin. The overall cumulative survival rate was poor in patients with SBP (42.5% and 22.5% at 6 and 12 months, respectively). At 7 days after treatment, the blood tests were similar between the two groups. In the ascitic fluid, the white blood cell counts decreased significantly and the protein concentrations tended to increase in both groups. In-hospital days, resolution rate of SBP, and in-hospital mortality rate were similar between the two groups. Although complication rates tended to be slightly higher in Group 1, long-term cumulative survivals were similar between Group 1 and Group 2. LVP was effective in removing abdominal discomfort in patients with tense ascites without serious complication. LVP with intravenous albumin was as effective as diuretics with intravenous albumin for the treatment of SBP with similar mortality. LVP with intravenous albumin might be feasible for the treatment of tense or refractory ascites in cirrhotic patients with SBP.

Chronic Albumin Infusions to Achieve Diuresis in Patients with Ascites Who Are Not Candidates for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

While transjugular intrahepatic portosystemic shunt (TIPS) is a common therapy for cirrhotic patients with diuretic-resistant or diuretic-refractory ascites, some patients are unsuitable for the procedure for technical or medical reasons. We report our experience with the use of chronic intravenous albumin infusions to achieve diuresis in this difficult patient population and review the historic experience of chronic albumin infusions as a treatment for ascites. Nineteen patients with cirrhosis and diuretic-resistant or diuretic-refractory ascites who were deemed unsuitable for TIPS received outpatient intravenous albumin infusions (50 g) weekly for at least 4 weeks. The following endpoints were retrospectively recorded: serum sodium, serum creatinine, blood urea nitrogen, hematocrit, bilirubin, albumin, international normalized ratio, body weight, and Model for End-stage Liver Disease (MELD) score. The contraindications for TIPS included the following: portal vein thrombosis, two; advanced age, one; encephalopathy, nine; hyperbilirubinemia, five; and other, two. Compared to pretreatment, posttreatment weight decreased in 17 patients, remained unchanged in 0 patients, and increased in 2 patients. The overall mean change in body weight (before vs. after therapy) was 8 lb (P < 0.05). The only significant change in biochemistry was an increase in serum albumin from 2.5 g/dl before therapy to 3.5 g/dl after therapy (P < 0.05). We conclude that (1) recurrent intravenous weekly albumin infusions resulted in significant loss of edema and ascites as measured by loss of body weight, and (2) clinicians may want to consider chronic albumin infusions for selected patients with refractory ascites who are not candidates for TIPS.

Trial for treatment of refractory ascites TIPS the scales

Trial for treatment of refractory ascites TIPS the scales

Hepatorenal Syndrome: A Dreaded Complication of End-Stage Liver Disease

Hepatorenal syndrome is the dreaded complication of end-stage liver disease characterized by functional renal failure due to renal vasoconstriction in the absence of underlying kidney pathology. The pathogenesis of hepatorenal syndrome is the result of an extreme underfilling of the arterial circulation secondary to an arterial vasodilation located in the splanchnic circulation. This underfilling triggers a compensatory response with activation of vasoconstrictor systems leading to intense renal vasoconstriction. The diagnosis is based on established diagnostic criteria aimed at excluding nonfunctional causes of renal failure. The prognosis of patients with hepatorenal syndrome is extremely poor especially in those who have a rapidly progressive course. Liver transplantation is the best option in suitable candidates, but it is not always applicable due to the short survival expectancy and donor shortage. Pharmacological therapies based on the use of vasoconstrictor drugs (terlipressin, midodrine, octreotide, or noradrenline) are the most promising in the aim of successfully offering a bridge to liver transplantation. Other treatments such as transjugular intrahepatic portosystemic shunts and albumin dialysis are effective but experience is very limited. Although there is limited information on the prevention of hepatorenal syndrome, intravenous albumin infusion in patients with spontaneous bacterial peritonitis and with oral pentoxifylline in patients with acute alcoholic hepatitis seems to effectively prevent hepatorenal syndrome in these two settings.

Cyclophosphamide and Immunoadsorption Apheresis Treatment of Lupus Nephritis Nonresponsive to Drug Therapy Alone

In this report we present a 28-year-old male patient with systemic lupus erythematosus (SLE) that was treated with immunoadsorption apheresis (IA) and cyclophosphamide for lupus nephritis (proliferative glomerulonephritis, class IV-B) after proving nonresponsive to drug therapy alone. Before starting the therapeutic cycle with IA, the patient was administered prednisone 25 mg/d, hydroxychloroquine 200mg twice/d, ACE inhibitors 5 mg/d, aspirin 100 mg/d, furosemide 50 mg/d, and intravenous (IV) albumin (20%) 50 mL. Deteriorating clinical conditions necessitated a renal biopsy, and thereafter an increase in medication. The patient was given a bolus of IV cyclophosphamide 1 g/d for 1 day and IV methylprednisone 500 mg/d for 3 days. This was not followed by any improvement and the renal functions worsened. Thus, 3 weeks after the more aggressive pharmacologic treatment with cyclophosphamide, which had been prescribed to improve renal function, and given the young age of the patient, the decision was made to administer IA (Selesorb). IA selectively removes IgG and IgM immune complexes from the plasma, thereby reducing the complications induced by the pathogenic autoimmune reaction. The treatment was administrated twice a week for the first 15 days, once a week for a further 5 weeks, and biweekly in the last month with a bolus of cyclophosphamide (average 250-100 mg) after each session. After twelve sessions of IA over 3 months, renal function was completely restored and the patient discharged. Although it is not proven, the concomitant use of cyclophosphamide could presumably improve the final clinical outcome.

Intravenous albumin did not prevent ovarian hyperstimulation syndrome in in vitro fertilization cycles

Intravenous albumin did not prevent ovarian hyperstimulation syndrome in in vitro fertilization cycles

Reconsidering hepatorenal syndrome

PREVIEWFor many years, hepatorenal syndrome was considered a uniformly and rapidly fatal complication of end-stage liver disease. Although the syndrome still carries a poor long-term prognosis, increased understanding of its hemodynamic derangements has led to new pharmacologic treatments that significantly improve short-term outcomes. In this article, Drs Tong, Hurley, and Hayashi discuss a case of remarkable reversal of hepatorenal syndrome with use of oral midodrine hydrochloride, subcutaneous octreotide acetate, and intravenous albumin. The authors highlight the great progress that has been made in this field and review new therapeutic options that are on the market or under study. It is important for physicians who are caring for patients with hepatorenal syndrome to know about and consider the available treatments before an approach of “supportive care only” is taken.

Intracranial clot lysis with intravenous microbubbles and transcranial ultrasound in swine.

Destruction of microbubbles by transcutaneous low-frequency ultrasound (LFUS) has been used to lyse adjacent clot and recanalize acutely thrombosed vessels. LFUS with intraarterial microbubbles has been shown to lyse cerebral clot rapidly in pigs without thrombolytic drugs. We hypothesized that intravenous platelet-targeted microbubbles with LFUS may be a rapid noninvasive technique to recanalize thrombosed intracerebral vessels. After angiography, 0.5 cc of autogenous thrombus was injected into 1 ascending pharyngeal artery of a pig, occluding it and the rete mirabile. These vessels connect the carotid to the internal carotid and are the main cerebral blood supply. Saline control or intravenous decafluorobutane-sonicated dextrose albumin microbubbles tagged with a subtherapeutic quantity of glycoprotein 2b/3a receptor inhibitor eptifibatide (75 U/kg plus 12 cc of microbubbles administered over 21 minutes), or eptifibatide control, was given with transcutaneous temporal LFUS (1 MHz at 2.0 W/cm2) for 24 minutes. Angiography followed with scoring of declotting and flow. The same protocol was repeated on the contralateral side with the other test fluid so each animal received a saline control and either tagged microbubble or eptifibatide alone. Fifteen pigs completed the protocol with a mean clot age of 4.6 hours. Using tagged microbubbles, 6 of 8 achieved success compared with 0 of 7 receiving eptifibatide alone (P=0.007) and 1 of 15 receiving saline alone (P=0.02). Intravenous platelet-targeted microbubbles combined with transcranial LFUS can rapidly open acute intracranial thrombotic occlusions. Further development for ischemic stroke therapy is justified.

Spontaneous bacterial peritonitis: a historical perspective: Kerr DNS, Pearson DT, Read AE. Infection of ascitic fluid in patients with hepatic cirrhosis [Gut 1963; 4: 394–398]; Conn HO. Spontaneous peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome [Ann Intern Med 1964; 60: 568–580

Spontaneous bacterial peritonitis: a historical perspective: Kerr DNS, Pearson DT, Read AE. Infection of ascitic fluid in patients with hepatic cirrhosis [Gut 1963; 4: 394–398]; Conn HO. Spontaneous peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome [Ann Intern Med 1964; 60: 568–580

Detection of retained microbubbles in carotid arteries with real-time low mechanical index imaging in the setting of endothelial dysfunction

We sought to determine if intravenously injected microbubbles would be retained by the carotid arteries (CAs) in the setting of endothelial dysfunction (ED) using a linear transducer equipped with a low mechanical index pulse sequence scheme (PSS). Microbubbles normally pass freely through large and small vessels but are retained in regions with ED. New high-frequency low mechanical index PSS can potentially be utilized to image these retained microbubbles. Intravenous albumin- and lipid-encapsulated microbubbles were administered in seven pigs while imaging the CAs before and after a 20% intralipid infusion to induce hypertriglyceridemia. The degree of microbubble retention was quantified by measuring endothelial acoustic intensity (AI) after clearance of free-flowing microbubbles. Microbubble adherence was also evaluated after selective balloon injury of the CAs. The CA diameter responses to acetylcholine were quantified. After induction of hypertriglyceridemia, adherence of albumin-encapsulated microbubbles was visually evident in all CAs, and endothelial AI increased significantly (p < 0.001 compared with baseline). The CA responses to acetylcholine went from vasodilation at baseline to vasoconstriction during hypertriglyceridemia. Endothelial AI also increased in the balloon-stretched vessels (p < 0.01 compared with uninjured vessels) after albumin-encapsulated microbubble injection, with a ring of microbubbles selectively adhering to the injured segment. This retention was not observed with lipid-encapsulated microbubbles. Scanning electron microscopy confirmed that albumin-coated microbubbles adhered to endothelial cells. Retention of intravenously injected albumin microbubbles occurs in the setting of both global and regional ED in large vessels and can be noninvasively imaged with high-frequency low mechanical index PSS.

Hepatorenal syndrome

Hepatorenal syndrome (HRS) is a major complication of patients with cirrhosis, with the annual incidence in patients with ascites being approximately 8% [ Bataller, Gines, Guevara, & Arroyo, 1997: Semin Liv Dis 17, 233]. This syndrome develops in the latest phase of the disease and there is now evidence that it is an important determinant of patient survival. Many aspects of HRS are, however, still poorly understood. There are two types of HRS: type 1 or progressive HRS which is associated with a very poor prognosis (median survival rate lower than 2 weeks), and Type 2 HRS which is characterized by a steady impairment in circulatory and renal function. The pathogenesis of HRS is a deterioration in effective arterial blood volume due to splanchnic arterial vasodilation and a reduction in venous return and cardiac output. It is therefore not surprising that the syndrome can be reversed by the simultaneous intravenous administration of albumin and arterial vasoconstrictors. Intrarenal mechanisms are also important and require prolonged improvement in circulatory function to be deactivated. Long-term administration of intravenous albumin and vasoconstrictors or the correction of portal hypertension with a transjugular intrahepatic portacaval shunt are effective in the treatment of HRS. They also appear to improve survival and may serve as a bridge to liver transplantation, which is the treatment of choice in these patients.

Albumin infusion for low serum albumin in preterm newborn infants.

Intravenous albumin infusion to treat hypoalbuminaemia is used in intensive care nurseries. Hypoalbuminaemia occurs in a number of clinical situations including prematurity, the acutely unwell infant, respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotising enterocolitis (NEC), intracranial haemorrhage, hydrops fetalis and oedema. Fluid overload is a potential side effect of albumin administration. Albumin is a blood product and therefore carries the potential risk of infection and adverse reactions. Albumin is also a scarce and expensive resource. The primary objective was to assess whether albumin infusions, in preterm neonates with low serum albumin, reduces mortality and morbidity. A secondary objective was to assess whether albumin infusion is associated with significant side effects. Searches were made of MEDLINE from 1966 to April 2004, CINAHL from 1982 to April 2004 and the current Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 1, 2004). Previous reviews (including cross references) and abstracts were also searched. All randomised controlled trials in which individual patients were allocated to albumin infusion versus control were included. Cross-over studies were excluded. Quasi randomised trials were excluded. Participants were preterm infants who had hypoalbuminaemia. Types of interventions included albumin infusion versus placebo (e.g. crystalloid) or no treatment. The reviewers worked independently to search for trials for inclusion and to assess methodological quality. Studies were assessed using the following key criteria: blinding of randomisation, blinding of intervention, completeness of follow up and blinding of outcome measurement. Only two small studies were found for inclusion in this review and only one reported clinically relevant outcomes - it found no significant differences for our primary outcome measure of death (RR 1.5 [95% confidence interval 0.3 - 7.43]) or secondary outcome measures of intraventricular haemorrhage, patent ductus arteriosus, necrotising enterocolitis, bronchopulmonary dysplasia, duration of mechanical ventilation and duration of oxygen therapy. There is a lack of evidence from randomised trials to determine whether the routine use of albumin infusion, in preterm neonates with low serum albumin, reduces mortality or morbidity, and no evidence to assess whether albumin infusion is associated with significant side effects. There is a need for good quality, double-blind randomised controlled trials to assess the safety and efficacy of albumin infusions in preterm neonates with low serum albumin.