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BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m810 (Published 28 February 2020) Cite this as: BMJ 2020;368:m810

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Albumin and its potential role in COVID-19

Dear Editor

Hypoalbuminemia is frequently observed in conditions like diabetes, hypertension and chronic heart failure, the cohort which is hardest hit with COVID-19 infection.(1)(2)(3) In our vast experience in India in a cardiac care unit, we have observed significant benefits of carefully administered albumin in patients with acute coronary syndrome, sepsis and septic shock.(4) Based on our observation we propose a trial of slow IV albumin with diuretics in COVID-19 patients suffering from ARDS along with hypoalbuminemia.

Amongst COVID-19 patients, those with low albumin levels have a poorer prognosis and low albumin levels are seen in 80% of the nonsurviving patients.(5) Its association with poor outcomes thus is conceivable since serum albumin maintains plasma oncotic pressure and acts as a carrier molecule for various endogenous and exogenous compounds. It has significant antioxidant properties responsible for maintaining plasma redox state.(6)

Although hypoalbuminemia is often an effect rather than the cause of the underlying pathology, targeted therapy with intravenous albumin has shown to improve serum albumin levels and improve respiratory, cardiovascular, and central nervous system components of the Sequential Organ Failure Assessment (SOFA) score.(7) In patients with acute lung injury in spite of altered capillary permeability, intravenous administration on IV albumin with diuretics improved oxygenation via increase in colloidal oncotic pressures, improved cardiac output and better ventilation–perfusion matching.(8)(9) A small pilot study has also shown favourable metabolic profile in patients of acute lung injury treated with I.V. albumin. (10)

In view of its abovementioned benefits, its trial is warranted in the current scenario of the COVID-19 pandemic. We have already registered a trial under Clinical trial Registry-India to examine the effect of intravenous infusion of albumin with diuretics in COVID-19 patients with respiratory insufficiency.

Competing interest : No competing interest.

1. Gopal D, Kalogeropoulos AP, Georgiopoulou VV, Tang WWH, Methvin A, Smith AL, et al. Serum Albumin Concentration and Heart Failure Risk. Am Heart J. 2010 Aug;160(2):279–85.
2. Stranges S, Rafalson LB, Dmochowski J, Rejman K, Tracy RP, Trevisan M, et al. Additional contribution of emerging risk factors to the prediction of the risk of type 2 diabetes: evidence from the Western New York Study. Obesity (Silver Spring). 2008 Jun;16(6):1370–6.
3. Guan W-J, Liang W, Zhao Y, Liang H, Chen Z, Li Y, et al. Comorbidity and its impact on 1,590 patients with COVID-19 in China: A Nationwide Analysis. 2020.
4. Sharma YP, Krishnappa D, Kanabar K, Kasinadhuni G, Sharma R, Kishore K, et al. Clinical characteristics and outcome in patients with a delayed presentation after ST-elevation myocardial infarction and complicated by cardiogenic shock. Indian Heart Journal. 2019 Sep 1;71(5):387–93.
5. Huang Y, Yang R, Xu Y, Gong P. Clinical characteristics of 36 non-survivors with COVID-19 in Wuhan, China. medRxiv. 2020 Mar 5;2020.02.27.20029009.
6. Taverna M, Marie A-L, Mira J-P, Guidet B. Specific antioxidant properties of human serum albumin. Ann Intensive Care. 2013 Feb 15;3:4.
7. Dubois M-J, Orellana-Jimenez C, Melot C, De Backer D, Berre J, Leeman M, et al. Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study*: Critical Care Medicine. 2006 Oct;34(10):2536–40.
8. Uhlig C, Silva PL, Deckert S, Schmitt J, Abreu MG de. Albumin versus crystalloid solutions in patients with the acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care. 2014 Feb;18(1):1–8.
9. Geer RT, Soma LR, Barnes C, Leatherman JL, Marshall BE. EFFECTS OF ALBUMIN AND/OR FUROSEMIDE THERAPY ON PULMONARY EDEMA INDUCED BY HYDROCHLORIC ACID ASPIRATION IN RABBITS: The Journal of Trauma: Injury, Infection, and Critical Care. 1976 Oct;16(10):788–91.
10. Park Y, Jones DP, Ziegler TR, Lee K, Kotha K, Yu T, et al. Metabolic effects of albumin therapy in acute lung injury measured by proton nuclear magnetic resonance spectroscopy of plasma: A pilot study*: Critical Care Medicine. 2011 Oct;39(10):2308–13.

Competing interests: No competing interests

24 April 2020
Dr Yash Paul Sharma
Professor and Head, Department of Cardiology
Dr Prashant Panda, Dr Lipi Uppal
Department of Cardiology, Advanced Cardiac Centre, Post graduate Institute of Medical Training and Research (PGIMER), Chandigarh, India