Efficacy of albumin with diuretics in mechanically ventilated patients with hypoalbuminemia: A systematic review and meta-analysis

Abstract

Background: Hypoalbuminemia is associated with fluid overload, the development of acute respiratory distress syndrome, and mortality. The co-administration of albumin and diuretics for the treatment of patients with hypoalbuminemia is expected to increase urine output, without hemodynamic instability, and improve pulmonary function; however, these effects have not been systematically investigated. Here, we aimed to clarify the benefits of the co-administration of albumin and diuretics in mechanically ventilated patients. Methods: We searched for randomized, placebo-controlled trials that investigated the effects of the co-administration of albumin and diuretics compared with placebo and diuretics, in mechanically ventilated patients with hypoalbuminemia. We searched these trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, and EMBASE databases. Primary outcomes were hypotensive events after the intervention, all-cause mortality, and the length of mechanical ventilation. Secondary outcomes were improvement in the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (P/F ratio) at 24 hours, total urine output (mL/d), and the clinical requirement of renal replacement therapy (RRT). Results: From the 1574 records identified, we selected 3 studies for quantitative analysis. The results of albumin administration were as follows: hypotensive events (risk ratio [RR] −1.05 [95% confidence interval {CI}: 0.15–0.81]), all-cause mortality (RR 1.0 [95% CI: 0.45–2.23]), the length of mechanical ventilation in days (mean difference −1.05 [95% CI: −3.35 to 1.26]), and improvement in P/F ratio (RR 2.83 [95% CI: 1.42–5.67]). None of the randomized controlled trials reported the total urine output, and one reported that no participants required RRT. Adverse events were not reported during the trials. The certainty of evidence was low (in the hypotensive events after the intervention and all-cause mortality) to moderate (in the length of mechanical ventilation in days, improvement of P/F ratio, clinical requirement of RRT, and adverse events). Conclusions: Although this treatment combination reduced the number of days for which mechanical ventilation was required, it did not reduce the all-cause mortality at 30 days. In conclusion, the co-administration of albumin and diuretics may reduce hypotensive events and improve the P/F ratio at 24 hours.

Human Albumin Infusion in Critically Ill and Perioperative Patients: Narrative Rapid Review of Meta-Analyses from the Last Five Years

“…Table 1 presents the selection scheme for the inclusion of scientific articles and their respective characteristics. Of the 12 meta-analyses, 6 were conducted in Asia [ 15 , 16 , 17 , 18 , 19 , 20 ], 3 in North America [ 13 , 21 , 22 ], and 3 in Europe [ 23 , 24 , 25 ]. These studies cover a range of critically ill and perioperative conditions, including critical illness in hospital or emergency settings [ 13 , 20 , 23 ], sepsis [ 15 , 16 ], cardiothoracic surgery [ 17 , 21 , 24 ], and acute brain injury, such as ischemic stroke [ 19 ] and traumatic brain injury [ 25 ].…”

“…Of the 12 meta-analyses, 6 were conducted in Asia [ 15 , 16 , 17 , 18 , 19 , 20 ], 3 in North America [ 13 , 21 , 22 ], and 3 in Europe [ 23 , 24 , 25 ]. These studies cover a range of critically ill and perioperative conditions, including critical illness in hospital or emergency settings [ 13 , 20 , 23 ], sepsis [ 15 , 16 ], cardiothoracic surgery [ 17 , 21 , 24 ], and acute brain injury, such as ischemic stroke [ 19 ] and traumatic brain injury [ 25 ]. In some studies on mechanical ventilation [ 20 ] and diuretic resistance [ 18 , 22 ], the particular roles of hypoalbuminemia were investigated.…”

“…These studies cover a range of critically ill and perioperative conditions, including critical illness in hospital or emergency settings [ 13 , 20 , 23 ], sepsis [ 15 , 16 ], cardiothoracic surgery [ 17 , 21 , 24 ], and acute brain injury, such as ischemic stroke [ 19 ] and traumatic brain injury [ 25 ]. In some studies on mechanical ventilation [ 20 ] and diuretic resistance [ 18 , 22 ], the particular roles of hypoalbuminemia were investigated. For review purposes, each study was assessed based on its country of origin, patient population, number of trials, size, intervention compared to control, outcomes evaluated, results, and methodological quality according to the AMSTAR-2 tool [ 14 ].…”

“…A third meta-analysis by Itagaki et al [ 20 ] investigated the effects of HA and diuretics co-administration in mechanically ventilated patients with hypoalbuminemia. Patients treated with HA and diuretics experienced a reduced number of days on mechanical ventilation, fewer hypotensive events, and improved oxygenation at 24 h. However, in the relatively small number of 129 patients of the three studies included in the meta-analysis, there was no significant effect on all-cause mortality at 30 days.…”

“…In addition to the study by Itagaki et al [ 20 ] on the mechanical ventilation of hypoalbuminemic adults receiving diuretic therapy, two meta-analyses [ 18 , 22 ] explored the effectiveness of HA administration in clinical contexts characterized by diuretic resistance and low serum albumin levels, a condition commonly associated with critical illness and seen in fluid overload.…”