BACKGROUND: Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis.
STUDY DESIGN AND METHODS: Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation.
RESULTS: The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused.
INTERPRETATION: Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.
| Discipline Area | Score |
|---|---|
| Surgery - Gastrointestinal |  |
| Internal Medicine | |
| Gastroenterology | |
| Intensivist/Critical Care | |
| Pediatric Hospital Medicine |  |
| Pediatric Neonatology | |
| Surgery - Cardiac | |
These are the most recent guidelines from the Chest Society about using intravenous albumin. Using albumin is common but the evidence is scant. This guideline suggests that intravenous albumin is recommended for patients with cirrhosis of the liver, although with low-certainty evidence. These guidelines provide the most recent evidence until more becomes available.
These guidelines provide recommendations on even low-grade evidence for most of the pathologies studied in pediatrics.
I can only comment on the neonatal recommendations. The recommendations are what I would have expected, given the lack of good RCT evidence to support using intravenous albumin in neonatal patients.
Using albumin has been debated both in pediatrics and neonatology for long time. This international guideline is based on systematic evaluation of the evidence and it focuses in two recommendation in neonates. Both recommendations are against using albumin and the certainty of evidence is rated very low. This is unsurprising as there are only a few randomized studies on albumin use in neonates, so the recommendations are based also on extrapolation from older children and adults. Further studies are needed.
