Human albumin administration in critically ill patients: systematic review of randomised controlled trials

BMJ 1998;317:235-240 ( 25 July )

Papers

Editorial by Offringa and Letters p 277

Cochrane Injuries Group Albumin Reviewers.

Cochrane Injuries Group, Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH

Ian.Roberts{at}ich.ucl.ac.uk

Objective: To quantify effect on mortality of administering human albumin or plasma protein fraction during managementof critically illpatients.
Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fractionwith no administration or with administration of crystalloid solutionin critically ill patients with hypovolaemia, burns, or hypoalbuminaemia.
Subjects: 30 randomised controlled trials including 1419 randomisedpatients.
Main outcome measure: Mortality from all causes at end of follow up for eachtrial.
Results: For each patient category the risk of death in the albumin treated group was higher than in the comparisongroup. For hypovolaemia the relative risk of death after albuminadministration was 1.46 (95% confidence interval 0.97 to 2.22),for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemiait was 1.69 (1.07 to 2.67). Pooled relative risk of death withalbumin administration was 1.68 (1.26 to 2.23). Pooled differencein the risk of death with albumin was 6% (95% confidence interval3% to 9%) with a fixed effects model. These data suggest thatfor every 17 critically ill patients treated with albumin thereis one additionaldeath.
Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia,burns, or hypoalbuminaemia and a strong suggestion that it mayincrease mortality. These data suggest that use of human albuminin critically ill patients should be urgently reviewed and thatit should not be used outside the context of rigorously conducted,randomised controlledtrials.

Key messages

Human albumin solution has been used in the treatment of critically ill patients for over 50 years
Currently, the licensed indications for use of albumin are emergency treatment of shock, acute management of burns, and clinical situations associated with hypoproteinaemia
Our systematic review of randomised controlled trials showed that, for each of these patient categories, the risk of death in the albumin treated group was higher than in the comparison group
The pooled relative risk of death with albumin was 1.68 (95% confidence interval 1.26 to 2.23) and the pooled difference in the risk of death was 6% (3% to 9%) or six additional deaths for every 100 patients treated
We consider that use of human albumin solution in critically ill patients should be urgently reviewed

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