Page 1978 - Hematology_ Basic Principles and Practice ( PDFDrive )

1752 Part XI Transfusion Medicine

compartment within 4 hours. Crystalloid may also provide volume in this context have resulted in no clinical benefit. However, other
expansion and is more quickly redistributed into total body fluids. studies have suggested that albumin use is associated with increased
Studies investigating the use of albumin in various situations includ- hypertension, respiratory distress, and electrolyte abnormalities.
ing volume expansion during and after surgery, as priming solution Consequently, the current recommended use of albumin for nephrotic
in cardiopulmonary bypass, or in maintaining colloid oncotic pres- syndrome patients is limited to patients in whom diuretic therapy is
sure, found no clinical benefit compared with controls. In 1998, the poorly tolerated or ineffective or in those with massive ascites or
Cochrane Injuries Group performed a systematic review of random- anasarca.
ized control trials in albumin treatment of critically ill patients and
concluded that there was no evidence that albumin use for volume
expansion reduces mortality in patients. They also suggested that Ovarian Hyperstimulation Syndrome
albumin increases mortality, but this conclusion was not confirmed
in later randomized control trials or subsequent metaanalyses. The OHSS is usually a result of iatrogenic administration of human
SAFE trial found in 6997 patients across 16 ICUs that there was no chorionic gonadotrophin (hCG) to induce ovulation. OHSS is typi-
difference in survival between those ICU patients who received fied by enlarged ovaries which release vascular endothelial growth
albumin versus normal saline. In another randomized study, the factor that can result in increased capillary permeability. This, in turn,
SAFE trial investigators found that albumin use was associated with leads to a fluid shift out of the intravascular compartment to the
a trend toward better outcomes in patients with severe sepsis 2-year abdominal/pleural spaces resulting in ascites and hypovolemia. In the
postrandomization. A smaller prospective study further revealed that most severe form, the patient can develop tense ascites, oliguria,
albumin was at least equivalent to plasma in clinical endpoints dyspnea, hemodynamic instability, and thromboembolism. Treat-
(perioperative/postoperative RBC transfusions, postoperative blood ment includes fluid restriction, analgesics, and close monitoring;
loss, duration of ICU stay, major complications) as a plasma expander occasionally hospitalization may be necessary.
in the context of pediatric craniofacial surgeries. One conclusion Mild OHSS occurs in approximately one-third and moderate-
from these prospective randomized trials is, contrary to previous severe in approximately 5% of women receiving exogenous hCG.
reports, the use of albumin is at least clinically equivalent to saline Increased risk of OHSS includes young age, low body weight, poly-
or plasma for intravascular volume resuscitation in some clinical cystic ovarian syndrome, high dose hCG, high or rapid rise in
settings. Moreover, the Italian Society of Transfusion Medicine and estradiol level, and previous history of OHSS. In addition, the risk
Immunohematology recently recommended that albumin may be is proportional to the number of developing follicles and number of
useful for hypovolemia in some patients with hemorrhagic shock, oocytes retrieved. Moderate-severe OHSS can be mitigated by closely
patients undergoing major surgery, such as cardiac surgery, patients monitoring women during treatment and subsequently withholding
with severe burns, and patients postliver transplant when crystalloids or reducing hCG administration when there is a large number of
and other colloids did not provide adequate clinical benefit. intermediate size developing follicles present or when estradiol levels
are elevated.
In 2011, the Cochrane collaboration systematically reviewed eight
Hypoalbuminemia randomized clinical trials of albumin administration in OHSS, and
concluded that there is only a borderline statistically significant
Low serum albumin is an independent predictor of morbidity and decrease in the incidence and severity of OHSS when albumin was
mortality in many clinical settings. However, correction of low serum administered during oocyte retrieval in high-risk women. In contrast,
albumin levels in ill patients does not improve outcome measures such the metaanalysis further revealed that the use of hydroxyethyl starch
as mortality. However, two randomized controlled studies showed that (HES) resulted in a markedly decreased incidence of severe OHSS.
correction of hypoalbuminemia did improve respiratory, cardiovascu- In addition, Bellver et al. published a large randomized trial that
lar, and central nervous system function. Current guidelines support demonstrated no difference in moderate-severe OHSS when 40 g of
the use of albumin to correct hypoalbuminemia for patients with albumin was administered after the retrieval of 20 or more oocytes.
ascites, large volume paracentesis, hepatorenal syndrome, and spon- Only one (nonrandomized) study to date has compared human
taneous bacterial peritonitis. Recent studies with albumin infusions albumin and 6% HES. This study concluded in 16 patients with
have also been done in end-stage liver disease patients for hypoalbu- severe OHSS that patients who received HES had a higher urine
minemia. However, results are less encouraging, with studies indicat- output, needed less abdominal paracentesis and drainage of pleural
ing no additional benefits or reduction in morbidity. effusions, and had a shortened hospital stay than patients who
received albumin. Therefore, while still clinically used, albumin may
be inferior to other therapies in the prevention of OHSS.
Cirrhosis
The use of albumin in cirrhotic patients dates to before 1950. In this Therapeutic Apheresis
setting, albumin was recommended for temporary improvement in
hyponatremia, spontaneous bacterial peritonitis, or prevention of the Albumin is the replacement fluid of choice for many apheresis indica-
complications associated with paracentesis, including volume shifts tions. Albumin reduces the risk of adverse events during apheresis
and hyponatremia, as noted earlier. Several studies demonstrated that procedures by reducing the risk of viral transmission, allergic reac-
after large-volume paracentesis (>5 L), hyponatremia and renal insuf- tions, and TRALI in comparison to plasma use (see plasma section).
ficiency were improved with albumin infusion compared with other Albumin can also be used in combination with saline during apheresis
volume-expanding agents. Moreover, a single randomized control procedures, but excessive use of saline results in hypotensive reactions.
trial of albumin use in cirrhotic patients with spontaneous bacterial Albumin is also indicated if large (>15% of the total blood volume)
peritonitis revealed that albumin administration with antibiotics blood volumes are removed to prevent hypotensive reactions in other
resulted in reduced mortality and a reduced risk of renal failure in therapeutic apheresis procedures (leukapheresis, plateletpheresis).
comparison with antibiotic use alone. While albumin is generally well tolerated in therapeutic apheresis
patients, albumin use can result in significant hypotension, bradycar-
dia, and flushing in patients receiving angiotensin converting enzyme
Nephrotic Syndrome inhibitor (ACE) therapy. ACE inhibitors prevent the patient’s ability
to metabolize bradykinins that are present in the albumin and acti-
Albumin has been used to increase colloid oncotic pressure with the vated during the apheresis procedure. In patients taking ACE inhibi-
intention of increasing diuresis via increasing vascular pressure at the tors, symptoms can be prevented by using plasma, or halting ACE
level of the glomerulus. Several studies have shown that albumin use inhibitor use and delaying the start of apheresis therapy.