Expert consensus on the use of human serum albumin in critically ill patients

Introduction Human serum albumin (HSA) is a non-glycosylated, negatively charged, single-chain polypeptide composed of 585 amino acid residues with a relative molecular mass of 66.438 kD. It is synthesized by the liver at a rate of approximately 200 mg·kg−1·day−1, with a half-life of 21 days, and subjected to catabolism in the muscles, liver, and kidneys at a rate of 4% per day.1 Albumin, accounting for 60% of the total plasma protein, has various physiological functions,2 such as maintaining 70% to 80% of effective plasma colloid osmotic pressure, coordinating vascular endothelial integrity, anti-oxidant and anti-inflammatory activities, maintaining the acid-base balance, and participating in the transport, distribution, and metabolism of a variety of endogenous and exogenous substances. The normal concentration of plasma albumin is 35 to 50 g/L. In clinical practice, hypoalbuminemia often occurs because of reduced albumin synthesis due to liver dysfunction, redistribution of serum albumin due to capillary leakage, or increased loss via the intestinal and renal routes. Hypoalbuminemia (defined as a serum albumin concentration less than 35 g/L) reportedly has an incidence of 24% to 87% in critically ill patients,3 while severe hypoalbuminemia (a serum albumin concentration less than 25 g/L) has an incidence of 5.0–9.6%.4 Hypoalbuminemia is an independent risk factor for increased short- and long-term mortality and an increased incidence of acute kidney injury (AKI) in patients with acute conditions such as trauma, cardiogenic shock, and sepsis.5 A meta-analysis showed that for every 10 g/L decrease in the serum albumin concentration in critically ill patients, there was a 137% increase in in-hospital mortality, an 89% increase in the incidence of comorbidities, and a 72% increase in the length of hospital stay.6 Hypoalbuminemia can also alter the pharmacokinetics of antibiotics, leading to either insufficient or excessively high blood concentrations, thereby resulting in treatment failure or excessive toxicity.7 HSA is mainly used for fluid resuscitation and the treatment of hypoproteinemia in critically ill patients.2 Existing studies have shown controversial results regarding whether the use of albumin in critically ill patients improves their clinical prognosis.8 Albumin consumption varies greatly among countries,9 and its inappropriate use is frequently seen, with 40% to 90% of reported HSA applications failing to follow clinical guidelines.10 A tertiary hospital in China reported that hypoproteinemia was the most common indication for the use of HSA (35.6%); however, it was also used in 11.8% of patients with serum albumin concentrations more than 40 g/L. The reason for its use was not documented in 22% of cases.11 In clinical practice, guidelines and consensus are lacking regarding the selection of HSA concentration, the timing of administration, dosage, and target concentration. Inappropriate use of HSA will cause adverse effects and increase medical costs inevitably, whereas guidance from clinical pharmacists or hospital standards can help reduce inappropriate HSA use by 30% and decrease medical costs without affecting patient prognosis.12 To further strengthen the standardized application of HSA in critically ill patients and achieve optimal clinical outcomes, the Chinese Society of Critical Care Medicine convened a panel of relevant experts who reviewed and summarized data on the clinical use of HSA, outlined 11 relevant clinical problems, and formulated the “Expert Consensus on the Use of Human Serum Albumin in Critically Ill Patients” using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Application Scope of the Consensus This consensus is mainly intended to propose recommendations relevant to critically ill patients through establishment of clinical problems, literature search, and comprehensive analysis with respect to 11 aspects: sepsis and septic shock, hemorrhagic shock, acute trauma, acute liver and adverse effects of HSA This consensus mainly as a for and clinical pharmacists on HSA Development of the Consensus The was in for the “Expert Consensus on the Use of Human Serum Albumin in Critically Ill Patients” of experts in and experts in and on a to relevant the experts that HSA has used for fluid resuscitation and albumin in critically ill patients, regarding the and the in clinical and treatment as as the that it was and to an consensus and recommendations to the and standardized use of HSA in The the clinical to and experts to the clinical using the and is for and for literature and relevant studies for The was and to clinical to insufficient literature in The 11 to in the consensus on as as panel and A of experts in was with experts a in of the literature and and for a as as the of the of the relevant consensus In from was for and clinical of the as as with of the the and for in or with and on and further the of in 25 The recommendations and using the in of and This was to a of consensus the a literature and the in a to the the of the consensus by the of and the at the of The was through of with high of for consensus on the use of serum albumin in critically ill not not Recommendations for the Use of HSA in the of and is a in the resuscitation of patients with sepsis and septic shock, with and effective of plasma the of and of The guidelines as the resuscitation fluid and albumin as a resuscitation there are recommendations regarding the timing of administration, optimal concentration, or for the of albumin for fluid resuscitation in patients with In consensus the and recommendations HSA is as a resuscitation fluid for patients with sepsis 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