A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients

Abstract

Background Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. Methods A randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. Results Sixty-five patients were submitted to 249 sessions; the mean age was 58 ($$\pm$$ ± 12), and 46 (70%) were male with a mean weight of 76 ($$\pm$$ ± 18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS − 8.25 ml/kg/h (− 11.18 5.80) vs. 8.27 ml/kg/h (− 12.22 to 5.53) with albumin, p = 0.011]. Conclusion In hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients. ClinicalTrials.gov Identifier: NCT04522635

Intravenous Albumin for the Prevention of Hemodynamic Instability During Sustained Low-Efficiency Dialysis. A Randomized Controlled Feasibility Trial. (The SAFER-SLED Study)

“…Despite evidence of widespread use of hyperoncotic albumin for the prevention or treatment of hemodynamic instability during RRT, few trials have directly addressed its e cacy (10,20). Our exploratory hemodynamic ndings are consistent with the results of a recent cross-over trial assessing the use of hyperoncotic albumin in hospitalized patients receiving hemodialysis (n = 65; 249 sessions) that included some sessions in ICU and also suggested that hyperoncotic albumin enhanced ultra ltration (11). To our knowledge, the only other trial to assess the use of hyperoncotic albumin in critically ill patients with AKI was an 8 person cross-over study that showed improved hemodynamics if 17.5% albumin was used as the priming solution for hemodialysis in septic patients with AKI (13).…”

“…Theoretically, it works by promoting intravascular plasma re lling from the extravascular compartment to compensate for uid removal with ultra ltration. While several small, cross-over trials have reported hemodynamic bene ts (11)(12)(13), no trial has been powered for clinically relevant outcomes. Furthermore intravenous albumin is expensive (14) and not without potential harms (10).…”

The Use of I.V. Albumin During Kidney Replacement Therapy: A Survey of Nephrologists and Intensivists

“…This aligns with other indirect evidence 4 that hemodynamic instability during KRT might decrease the likelihood of kidney recovery after AKI. Intravenous hyperoncotic albumin may prevent hemodynamic instability and facilitate targeted ultrafiltration in critically ill patients on KRT 5,6 but it is very costly and has a weak evidence base. 7 Despite this, there is some evidence that intravenous albumin is already frequently prescribed for this indication.…”

Einsatz von Albumin

“…Neue Studiendaten zum Einsatz von HA in der Nierenersatztherapie existieren für die Behandlung der intradialytischen Hypotonie (IDH; [36]) und für die Verbesserung des Flüssigkeitsentzugs unter kontinuierlicher Nierenersatztherapie (CRRT; [43]).…”

“…In der Studie wurde jeweils zu Beginn der Dialyse randomisiert und es wurden 100 ml von entweder 0,9 % NaCl oder HA 25 % intravenös verabreicht. Die HA-Gabe vor der Dialyse führte zu weniger Episoden von Hypotonie [36].…”