Two studies published in the Journal suggested that the use of
colloid, or more specifically albumin, solutions in the resuscitation of
critically ill patients may be associated with greater mortality and
morbidity than the use of crystalloids.1 2 Following media publicity
engendered by these papers, the parents of some children with the
nephrotic syndrome have expressed alarm when the question of albumin
administration was raised. Although the weight of evidence suggests that
most patients with minimal change, steroid sensitive nephrotic syndrome in
stable relapse are not hypovolaemic, there is undoubtedly a subgroup of
children who present in acute relapse with symptoms strongly suggestive of
hypovolaemia (abdominal pain, peripheral vasoconstriction, oliguria and
sometimes postural hypotension), and these symptoms are rapidly and
reliably relieved by albumin infusion. Studies of renal sodium handling
and vasoactive hormone profiles3 provide additional evidence for a state
of functional hypovolaemia in such patients, as does the finding of marked
elevation of the haemoglobin concentration and haematocrit.
The possibility that albumin infusion may be dangerous in critically
ill patients, even if true, should not lead by extrapolation to its
inappropriate withholding from nephrotic patients with clinical and
laboratory evidence of hypovolaemia, in whom it is not only effective in
relieving symptoms but may also protect against the relatively rare but
serious complications of vascular thrombosis and acute renal failure. It
is not my intention to promote the routine or casual use of albumin in
children who do not need it: indeed, the intravenous administration of
albumin to nephrotic patients who are not hypovolaemic is very dangerous.4
Albumin infusion should be considered in children in nephrotic relapse who
have symptoms and signs of hypovolaemia, supported by evidence of avid
renal sodium retention (low fractional sodium excretion, or as an
acceptable proxy, urine sodium concentration of <_10 mmol="mmol" l.="l." a="a" dose="dose" of="of" _1="_1" g="g" kg="kg" dry="dry" body="body" weight="weight" should="should" be="be" given="given" by="by" intravenous="intravenous" infusion="infusion" over="over" _4="_4" hours.="hours." the="the" patient="patient" closely="closely" monitored="monitored" and="and" stopped="stopped" frusemide="frusemide" if="if" signs="signs" volume="volume" overload="overload" appear="appear" however="however" selection="selection" is="is" appropriate="appropriate" according="according" to="to" above="above" criteria="criteria" this="this" an="an" unusual="unusual" event.="event." these="these" guidelines="guidelines" have="have" been="been" published="published" in="in" more="more" detail="detail" consensus="consensus" statement="statement" on="on" management="management" childhood="childhood" nephrotic="nephrotic" syndrome="syndrome" british="british" association="association" for="for" paediatric="paediatric" nephrology="nephrology" bapn.5="bapn.5" p="p"/> George Haycock, Professor of Paediatrics, on behalf of the British
Association for Paediatric Nephrology
Department of Paediatrics, 12th Floor, Guy's Tower, Guy's Hospital, London
SE1 9R
1 Schierhout G, Roberts I. Fluid resuscitation with colloid or
crystalloid solutions: a systematic review of randomised trials. British
Medical Journal 1998;316:961-964.
2 Cochrane Injuries Group Albumin Reviewers. Human albumin
administration in critically ill patients: systematic review of randomised
controlled trials. British Medical Journal 1998;317:235-240.
3 Vande Walle JG, Donckerwolcke RAMG, Wimersma Greidanus TB, Joles
JA, Koomans HA. Renal sodium handling in children with nephrotic relapse:
relation to hypovolaemic symptoms. Nephrology Dialysis Transplantation
1996;11:2202-2208.
4 Reid CJ, Marsh MJ, Murdoch IM, Clark G. Nephrotic syndrome in
childhood complicated by life threatening pulmonary oedema. British
Medical Journal 1996;312(7022):36-8.
5 Anonymous. Consensus statement on management and audit potential
for steroid responsive nephrotic syndrome. Report of a Workshop by the
British Association for Paediatric Nephrology and Research Unit, Royal
College of Physicians. Archives of Disease in Childhood 1994;70(2):151-7.
Rapid Response:
Dangers of intravenous albumin infusion
EDITOR-
Two studies published in the Journal suggested that the use of
colloid, or more specifically albumin, solutions in the resuscitation of
critically ill patients may be associated with greater mortality and
morbidity than the use of crystalloids.1 2 Following media publicity
engendered by these papers, the parents of some children with the
nephrotic syndrome have expressed alarm when the question of albumin
administration was raised. Although the weight of evidence suggests that
most patients with minimal change, steroid sensitive nephrotic syndrome in
stable relapse are not hypovolaemic, there is undoubtedly a subgroup of
children who present in acute relapse with symptoms strongly suggestive of
hypovolaemia (abdominal pain, peripheral vasoconstriction, oliguria and
sometimes postural hypotension), and these symptoms are rapidly and
reliably relieved by albumin infusion. Studies of renal sodium handling
and vasoactive hormone profiles3 provide additional evidence for a state
of functional hypovolaemia in such patients, as does the finding of marked
elevation of the haemoglobin concentration and haematocrit.
The possibility that albumin infusion may be dangerous in critically
ill patients, even if true, should not lead by extrapolation to its
inappropriate withholding from nephrotic patients with clinical and
laboratory evidence of hypovolaemia, in whom it is not only effective in
relieving symptoms but may also protect against the relatively rare but
serious complications of vascular thrombosis and acute renal failure. It
is not my intention to promote the routine or casual use of albumin in
children who do not need it: indeed, the intravenous administration of
albumin to nephrotic patients who are not hypovolaemic is very dangerous.4
Albumin infusion should be considered in children in nephrotic relapse who
have symptoms and signs of hypovolaemia, supported by evidence of avid
renal sodium retention (low fractional sodium excretion, or as an
acceptable proxy, urine sodium concentration of <_10 mmol="mmol" l.="l." a="a" dose="dose" of="of" _1="_1" g="g" kg="kg" dry="dry" body="body" weight="weight" should="should" be="be" given="given" by="by" intravenous="intravenous" infusion="infusion" over="over" _4="_4" hours.="hours." the="the" patient="patient" closely="closely" monitored="monitored" and="and" stopped="stopped" frusemide="frusemide" if="if" signs="signs" volume="volume" overload="overload" appear="appear" however="however" selection="selection" is="is" appropriate="appropriate" according="according" to="to" above="above" criteria="criteria" this="this" an="an" unusual="unusual" event.="event." these="these" guidelines="guidelines" have="have" been="been" published="published" in="in" more="more" detail="detail" consensus="consensus" statement="statement" on="on" management="management" childhood="childhood" nephrotic="nephrotic" syndrome="syndrome" british="british" association="association" for="for" paediatric="paediatric" nephrology="nephrology" bapn.5="bapn.5" p="p"/> George Haycock, Professor of Paediatrics, on behalf of the British
Association for Paediatric Nephrology
Department of Paediatrics, 12th Floor, Guy's Tower, Guy's Hospital, London
SE1 9R
1 Schierhout G, Roberts I. Fluid resuscitation with colloid or
crystalloid solutions: a systematic review of randomised trials. British
Medical Journal 1998;316:961-964.
2 Cochrane Injuries Group Albumin Reviewers. Human albumin
administration in critically ill patients: systematic review of randomised
controlled trials. British Medical Journal 1998;317:235-240.
3 Vande Walle JG, Donckerwolcke RAMG, Wimersma Greidanus TB, Joles
JA, Koomans HA. Renal sodium handling in children with nephrotic relapse:
relation to hypovolaemic symptoms. Nephrology Dialysis Transplantation
1996;11:2202-2208.
4 Reid CJ, Marsh MJ, Murdoch IM, Clark G. Nephrotic syndrome in
childhood complicated by life threatening pulmonary oedema. British
Medical Journal 1996;312(7022):36-8.
5 Anonymous. Consensus statement on management and audit potential
for steroid responsive nephrotic syndrome. Report of a Workshop by the
British Association for Paediatric Nephrology and Research Unit, Royal
College of Physicians. Archives of Disease in Childhood 1994;70(2):151-7.
Competing interests: No competing interests