Topic Review Albumin

R3 Topic review
Albumin
R3: 郭弘誼
Supervisor: 謝宗達醫師
• Approximately 15 g per day (200 mg/kg per da
y) synthesized in liver
• 35 ～ 50% of total protein in total serum
• Child: 2.8 ～ 4.4 g/dL
• Adult: 3.5 ～ 5.2 g/dL
• Old: 3.4 ～ 4.4 g/dL
Junge W, Bossert-Reuther S, Klein G, et al. Clin Chem Lab Med (June 2007 Poster EUROMEDLAB)
Dati F, Schumann G, Thomas L, et al. Eur J Clin Chem Clin Biochem 1996;34:517-520.
Burtis CA, Ashwood ER, Bruns DE, eds. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, 4 th ed Philadelphia, PA:
WB Saunders 2006:549
When? Where? Why?
World War I
Albumin 的製造
• Edwin Joseph Cohn: protein chemist
• Led Harvard team developed the first industria
l-scale process to manufacture an infusible alb
umin product
• Cohn is regarded as the father of plasma fracti
onation
國血製劑益康的意義
• 照護國民健康
- 善用國人高品質捐血之血漿
- 提升血液製劑品質安全，確保貨源穩定
- 國人自有抗體之附加價值開發應用
- 避免引國外之傳染病源
• 維護國防安全
911 事件時 ( 上午 8:46 衝撞 ) ，歐洲禁止血液製劑輸出且美國國民兵進
駐血液製劑工廠 ( 上午 11 點 )
From 國血製劑益康手冊
配合國血國用， since 2007/1
How to examine?
Albumin 的小秘密
• Dye binding methods
• 利用色素和血液中白蛋白結合再測其吸光
度以反推其濃度
• Bromocresol Purple （ BCP ）與 Bromocreso
l Green （ BCG ）兩種方法，各在不同情況
下有不同結果
pH 4.2
Albumin + BCG BCG complex
溶血會影響 ??
• Conjugated and Unconjugated billiribin  no s
ignificant interference
• Hemolysis  no significant interference
• Lipemia  no significant interference
• Drug  no significant interference
Glick MR, Ryder KW, Jackson SA. Clin Chem 1986;32:470-475

Breuer J. Eur J Clin Chem Clin Biochem 1996;34:385-386
Sonntag O, Scholer A. Ann Clin Biochem 2001;38:376-385
Type IgM (Waldenstrom’s macroglobulinemi
a)
• Lymphoplasmacytic lymphoma
• Cancer affecting lymphoplasmacytoid cells an
d plasma cells
• High level IgM
• May cause unreliable results of albumin
Bakker AJ, Mücke M Clin Chem Lab Med. 2007;45(9):1240-3.

The lower, the worsen?
The worsen, the lower?
EXPERT REVIEW OF CLINICAL PHARMACOLOGY, 2018
https://doi.org/10.1080/17512433.2018.1412827
Gibbs–Donnan effect
Bianchetti MG, Simonetti GD, Bettinelli A - Ital J Pediatr (2009)

J. Mol. Biol. (2005) 353, 38–52
使用 Human Albumin 以符合下列適應症為限：
(1) 休克病人擴充有效循環血液量
• Ⅰ. 休克病人至少已給生理鹽水或林格爾液等晶類溶液 1000 mL 後尚不能維持穩定血
流動態，血比容 (hematocrit) ＞ 30 % ，或血色素 (hemoglobin) ＞ 10 gm/dL 須要繼續靜脈
輸液時，宜優先使用合成膠類溶液，如 dextran 、 hydroxyethylstarch 、 polyvinylpyrolidon
e 等。若無上述合適製劑，可給白蛋白溶液，每一病人用量限 50 gm 。
• Ⅱ. 70 歲以上老人及二歲以下幼兒或併有心衰竭的休克病人，無法忍受太多靜脈輸液
時，可一開始即使用白蛋白溶液，每一病人用量限 50 gm 。
(2) 病危、有腹水或水腫併有血清白蛋白濃度偏低病人
• Ⅰ 血清白蛋白濃度低於 2.5 gm/dL
a. 肝硬化症 ( 有相當之腹水或併發水腫 ) 每日最多用量限 25 gm 。
b. 腎病症候群 ( 嚴重蛋白尿致血清白蛋白下降 ) ，每日最多用量限 25 gm 。
c. 嚴重燒燙傷。
d. 肝移植。
e. 蛋白質流失性腸症 (protein-losing enteropathy)
• II 血清白蛋白濃度低於 3.0 gm/dL
a. 嚴重肺水腫。
b. 大量肝切除（＞ 40 % ）
c. 開心手術用於維持體外循環液，用量限 37.5 gm 。
病人水腫且 albumin 又低
打個 furosemide 跟白蛋白吧
Mechanism of furosemide resistance in analbumine
mic rats and hypoalbuminemic patients Kidney Inter
national, Vol. 32 (1987)
Inoue M, Okajima K, Itoh K, et al
• Furosemide is an organic anion that binds stro

ngly to albumin
• Study diuretic on urine volume of normal and
analbuminemic rats (NAR) and of hypoalbumi
nemic patient
• Use furosemide or furosemide + albumin
NAR rats
Normal
rats
Kidney Int. 1987 Aug;32(2):198-203.

Kidney Int. 1987 Aug;32(2):198-203.
Kidney Int. 1987 Aug;32(2):198-203.
Kidney Int. 1987 Aug;32(2):198-203.
Co-administration of albumin and furosemide in patie
nts with the nephrotic syndrome
Kidney Int. 1999 Feb;55(2):629-34.
Fliser D, Zurbrüggen I, Mutschler E, et al
• Double-blind, placebo-controlled study

• 9 nephrotic patients
(a) 60 mg FU plus a sham infusion

(b) 60 mg FU plus 200 ml of a 20% solution of HA
(c) sham infusion plus 200 ml of a 20% solution of HA
Kidney Int. 1999 Feb;55(2):629-
Kidney Int. 1999 Feb;55(2):629-
Co-administration of albumin and furosemide in
patients with the nephrotic syndrome
Kidney Int. 1999 Feb;55(2):629-34.
Fliser D, Zurbrüggen I, Mutschler E, et al
• Co-administration of HA increases the natriure

tic action of FU in patients with the nephrotic s
yndrome.
• The effect appears to be mainly mediated by c
hanges in renal hemodynamics
Kidney Int. 1999 Feb;55(2):629-

Albumin improves the response to diuretics in patients with cirrh
osis and ascites: results of a randomized, controlled trial
Journal of Hepatology 1999; 30: 639-645
Protocol 1
Group A: diuretics alone (furosemide +

spironolactone)
Group B: diuretics + albumin (12.5 g/day)

Protocol 2
Group A: diuretics alone (furosemide +

spironolactone)
Group B: diuretics + albumin (25 g once a week in the

first year and 25 g every 2 weeks in the second and third years)
• Albumin is effective in improving the rate of re

sponse and preventing recurrence of ascites in
cirrhotic patients with ascites receiving diureti
cs.
• 貴!
• Albumin is effective in improving the rate of re

sponse and preventing recurrence of ascites in
cirrhotic patients with ascites receiving diureti
cs. Protocol 1: 45200 USD
• 貴!
Protocol 2: 228000 USD

Effects of Albumin/Furosemide Mixtures on Responses to Fur
osemide in Hypoalbuminemic Patients
J Am Soc Nephrol 12: 1010–1016, 2001
Chalasani N, Gorski JC, Horlander JC Sr
• Randomized crossover study
• 13 liver cirrhosis patients
(1) 40 mg of furosemide
(2) 25 g of albumin
(3) 40 mg of furosemide and 25 g of albumin premixed
ex vivo
(4) 40 mg of furosemide and 25 g of albumin infused si
multaneously into different arms
J Am Soc Nephrol 12: 1010–1016, 2001
<
J Am Soc Nephrol 12: 1010–1016, 2001

Urinary sodium excretion rate
J Am Soc Nephrol 12: 1010–1016, 2001

Urinary excretion rate of furosemide
J Am Soc Nephrol 12: 1010–1016, 2001

Effects of Albumin/Furosemide Mixtures on Responses t
o Furosemide in Hypoalbuminemic Patients
J Am Soc Nephrol 12: 1010–1016, 2001
• Albumin administered in an ex vivo mixture wit
h furosemide or administered simultaneously w
ith furosemide did not enhance diuretic effects i
n patients with cirrhosis and ascites
• Therefore, the co-administration of albumin and
furosemide for the treatment of cirrhosis, and li
kely other hypoalbuminemic conditions, should
not be used clinically.
• 沒效 !!
The added-up albumin enhances the diuretic effect of furosemide
in patients with hypoalbuminemic chronic kidney disease: a rand
omized controlled study
BMC Nephrology 2012, 13:92
Phakdeekitcharoen B, Boonyawat K
• 24 patients
• Randomized controlled crossover study
• CKD patients (GFR = 31.0 ± 13.8 mL/min) with
hypoalbuminemia (2.98 ± 0.30 g/dL)
• Furosemide(40mg) or furosemide(40mg) + alb
umin(10g)
The added-up albumin enhances the diuretic effect of furosemide
in patients with hypoalbuminemic chronic kidney disease: a rand
omized controlled study
Phakdeekitcharoen B, Boonyawat K
• In conclusion, our studies have demonstrated

that the combination of furosemide and albu
min have a superior short-term efficacy over f
urosemide alone in enhancing water and sodi
um diuresis in stable hypoalbuminemic chroni
c kidney disease patients
Co-administration of furosemide with albumin for overcoming diuretic re
sistance in patients with hypoalbuminemia: A meta-analysis
Journal of Critical Care 29 (2014) 253–259
Co-administration of furosemide with albumin for overcoming diuretic re
sistance in patients with hypoalbuminemia: A meta-analysis
Journal of Critical Care 29 (2014) 253–259
• The cumulative evidence analyzed here does n

ot provide any justification for routine adoptio
n of FUR-ALB to overcome diuretic resistance i
n hypoalbuminemic patients.
• Statistically significant diuretic and natriuretic
effects were transient, and of limited clinical si
gnificance and generalizability
使用 Human Albumin 以符合下列適應症為限：
(1) 休克病人擴充有效循環血液量
• Ⅰ. 休克病人至少已給生理鹽水或林格爾液等晶類溶液 1000 mL 後尚不能維持穩定血
流動態，血比容 (hematocrit) ＞ 30 % ，或血色素 (hemoglobin) ＞ 10 gm/dL 須要繼續靜脈
輸液時，宜優先使用合成膠類溶液，如 dextran 、 hydroxyethylstarch 、 polyvinylpyrolidon
e 等。若無上述合適製劑，可給白蛋白溶液，每一病人用量限 50 gm 。
• Ⅱ. 70 歲以上老人及二歲以下幼兒或併有心衰竭的休克病人，無法忍受太多靜脈輸液
時，可一開始即使用白蛋白溶液，每一病人用量限 50 gm 。
(2) 病危、有腹水或水腫併有血清白蛋白濃度偏低病人
• Ⅰ 血清白蛋白濃度低於 2.5 gm/dL
a. 肝硬化症 ( 有相當之腹水或併發水腫 ) 每日最多用量限 25 gm 。
b. 腎病症候群 ( 嚴重蛋白尿致血清白蛋白下降 ) ，每日最多用量限 25 gm 。
c. 嚴重燒燙傷。
d. 肝移植。
e. 蛋白質流失性腸症 (protein-losing enteropathy)
• II 血清白蛋白濃度低於 3.0 gm/dL
a. 嚴重肺水腫。
b. 大量肝切除（＞ 40 % ）
c. 開心手術用於維持體外循環液，用量限 37.5 gm 。
休克用白蛋白 ?
Photo Source : s-media-cache-ak0.pinimg.com
Septic shock
Oregon Medical Malpractice and Personal Injury Attorneys http://www.aferetica.com/en/sepsis/

• 輸白蛋白比較不容易肺水腫吧 !?
• 膠體溶液會在血管中殘留久一點，對穩定
血壓更有效吧 !?
• 37 patients with hypovolemia
• Use colloids or crystalloids to maintained MAP
or urine amount
Circulation, Volume 52, September 1975

Crystalloid vs colloid in the etiology of pulmonary failure after
trauma: a randomized trial in man.
Surgery. 1977;81:676-683 Lowe RJ, Moss GS, Jilek J, Levine HD.
• Randomized trial
• 141 trauma patients need surgery
• LR compared with LR given with albumin
• No significant differences in
(1) survival rate
(2) incidence of pulmonary failure
(3) postoperative pulmonary function
• Virgilio RW, Rice CL, Smith DE, et al. Crystalloid vs. colloid
resuscitation: is one better? Surgery. 1979;85:129-139.
• Moss GS, Lowe RJ, Jilek J, Levine HD. Colloid or crystalloid
in the resuscitation of hemorrhagic shock: a controlled cli
nical trial. Surgery. 1981;89:434-438.
• Zetterstrom H. Albumin treatment following major surger
y, II: effects on postoperative lung function and circulator
y adaptation. Acta Anaesthesiol Scand. 1981;25:133-141.
• Shires TG, Peitzman AB, Albert SA, et al. Response of extr
avascular lung water to intraoperative fluids. Ann Surg. 1
983;197:515-519.
Fluid resuscitation in circulatory shock: a comparison ofthe cardiorespiratory e
ffects ofalbumin, hetastarch, and saline solutions in patients with hypovolemi
a and septic shock.
Rackow EC, Falk JL, Fein A, et al.
• Prospective, randomized study

• 26 patients requiring resuscitation for hypovol
emic shock
• Randomized to receive 250 mL of 5% albumin,
6% hetastarch, or saline
Crit Care Med. 1983;11:839-850.

a and septic shock.
• No significant differences in any of the hemodynamic meas

ures
• Saline-treated group (8355.5 ± 1874.3 mL) required more f
uids than the albumin- (2833.3 ± 266.8 mL) and hetastarch-
treated (4568.6±1201.8 mL) groups (P<0.05).
• The COP : Saline-treated group (14.7 ±0.7 mm Hg ) albumin
group (21.5 ± 1.4 mmHg) and hetastarch-treated (23.5 ± 1.
3 mm Hg) groups
• PE found in 22% of the patients in the albumin- and hetasta
rch-treated groups compared with 87.5% in the saline-treat
ed group (P<0.05).
Crit Care Med. 1983;11:839-850.
a and septic shock.
• No significant differences in any of the hemodynamic meas

ures
• Saline-treated group (8355.5 ± 1874.3 mL) required more f
uids than the albumin- (2833.3 ± 266.8 mL) and hetastarcht
reated (4568.6±1201.8 mL) groups (P<0.05).
• The COP : Saline-treated group (14.7 ±0.7 mm Hg ) albumin
group (21.5 ± 1.4 mmHg) and hetastarchtreated (23.5 ± 1.3
mm Hg) groups
• PE found in 22% of the patients in the albumin- and hetasta
rch-treated groups compared with 87.5% in the saline-treat
ed group (P<0.05).
Crit Care Med. 1983;11:839-850.
Large Volume Crystalloid Resuscitation Does Not Increase
Extravascular Lung Water
T. James Gallagher, MD, Michael J. Banner, RRT, and Peggy A. Bar
nes, MD
• Ten sheep anesthetized were bled to a mean a
rterial pressure (MAP) of 50 mm Hg
• Use Ringer’s lactate solution to keep MAP at le
ast 1 hour
• Check colloid oncotic pressure (COP), extravas
cular lung water (EVLW), pulmonary capillary
wedge pressure (PCWP)
ANESTH ANALG 1985;64:323-6

Large Volume Crystalloid Resuscitation Does Not Increase
Extravascular Lung Water
T. James Gallagher, MD, Michael J. Banner, RRT, and Peggy A. Bar
nes, MD
ANESTH ANALG 1985;64:323-6

BMJ. 1998 Jul 25; 317(7153): 235–240.
BMJ 1998;317:235–40
BMJ 1998;317:235–40
Human albumin administration in critically ill patients:
systematic review of randomised controlled trials
Cochrane Injuries Group Albumin Reviewers
• There is no evidence that albumin administrati
on reduces mortality in critically ill patients wit
h hypovolaemia, burns, or hypoalbuminaemia
• This RCT revealed suggestion that it may incre
ase mortality
BMJ 1998;317:235–40
NEJM
N Engl J Med 2004 May 27;350(22):2247-

56.
The SAFE Study
• 16 ICUs in Australia and New Zealand
• Patients 18 years of age or older whom the tre
ating clinician judged to require fuid administr
ation to maintain or increase intravascular vol
ume
• Received 4 percent albumin (Albumex, CSL) or
normal saline (0.9% NaCl)
• 3473 in Albumin group : 3460 in Saline group
ICU Book Fig 12.2
約 3 : 1 ICU Book Fig 12.2
Day 1 1 : 1.3 (saline group 多約 400ml)
Day 1 5368 : 94 (saline group 便宜 5274 元 )
Increased relative risk of using albumin
among the brain trauma injury group!!!!
The SAFE Study
• 兩組人在 ICU 的住院天數跟呼吸器使用天數
差不多
• 兩組人的 28 天跟 90 天死亡率也沒差異
• 白蛋白沒特別有效跟好用
• 但是好像沒壞處 !?
JAMA 2013 Nov 6;310(17):1809-17
JAMA November 6, 2013 Volume 310, Number 17
The CRISTAL Randomized Trial
crystalloids group colloids group
• Isotonic saline (0.9% NaCl) • Hypooncotic (eg, gelatins, 4
• Buffered solutions (eg, Ring % or 5% of albumin)
er lactate, acetate, maleate) • Hyperoncotic (eg, dextrans,
hydroxyethyl starches, and 2
0%or 25%of albumin)
2000 : 3000ml
(1 : 1.5 )
P<0.01

No significant heterogeneity in the effect of treatment on mortality in

any of the predefined strata in 90 days
• 使用 colloid 沒什麼特別壞處
• 使用 colloid 好像對血壓稍微好一點
• 28 天死亡率沒差異
• 90 天死亡率可能好像似乎 colloid 好一點點
，但需要更多研究…
N Engl J Med. 2014 Apr 10;370(15):1412-21
Albumin Italian Outcome Sepsis
(ALBIOS) study
• Investigator-initiated
• Multicenter
• Open-label
• Randomized, controlled trial — in 100 intensiv
e care units (ICUs) in Italy
The ALBIOS study
Albumin group Crystalloid group
• 20% albumin and crystalloid • Crystalloid fuid only
solution
• 300 ml of 20% albumin solu
tion
• maintain a serum albumin l
evel of 30 g per liter or mor
e
• No synthetic colloids
Serum albumin
n engl j med 370;15 april 10, 2014

Net fuid balance

The ALBIOS study

The ALBIOS study
• 28 天跟 90 天的死亡率沒啥差
• 如果細分是 septic shock 病人，使用 albumi
n 好像有一點點好處
• 使用 albumin 的好像可以比較快 off 升壓劑
，但是大概快 1 天，不過用量就…
Other possible beneficial effects
8.Brink AJ, Richards GA, Lautenbach EE, et al. Int J Antimicrob Agents. 2015;45(6):647-651.
9.Oettl K, Birner-Gruenberger R, Spindelboeck W, et al. J Hepatol. 2013;59(5): 978-983.
12. Bortoluzzi A, Ceolotto G, Gola E, et al. Hepatology. 2013;57(1):266-276.
13. O’Brien AJ, Fullerton JN, Massey KA, et al. Nat Med. 2014;20(5):518-523.
14. Zeng Y, Adamson RH, Curry FR, et al. Am J Physiol Heart Circ Physiol. 2014;306(3):H363-H372.
15. Giannone FA, Domenicali M, Baldassarre M, et al. Liver Int. 2015;35(11):2425-2432.
16. Finfer S, McEvoy S, Bellomo R, et al. Intensive Care Med. 2011;37(1):86-96.
Septic shock
Oregon Medical Malpractice and Personal Injury Attorneys http://www.aferetica.com/en/sepsis/

Sepsis induced endothelial dysfunction the
n involved in microcirculatory blood fow i
mpairment
Ait-Oufella H, Maury E, Lehoux S, Guidet B, Offenstadt G (2010) The endothelium: physiological functions and
role in microcirculatory failure during severe sepsis. Intensive Care Med 36(8):1286–1298
https://linkinghub.elsevier.com/retrieve/pii/B9780124158245000084?via=sd&cc=y
Luca Zazzerona et al, Curr Opin Crit Care 2016, 22:428–436
想知道更多資訊關於 Glycocalyx?
Albumin infusion improves endothelial
function in septic shock patients: a pilot study (Intensiv
e Care Med)
Albumin group Control group
• Check skin endothelial func • Check skin endothelial func
tion before and 1 h after vol tion before and 1 h after vol
ume expansion ume expansion
• 100-mL bolus HSA 20% over • 500-mL bolus saline
15 min
Albumin infusion improves endothelial function in septic shock patients: a pilot study (2018 Intensive Care Med)
Intensive Care Med (2017) 43:304–377
Sepsis guideline 2016
• We suggest using albumin in addition to crysta
lloids for initial resuscitation and subsequent i
ntravascular volume replacement in patients
with sepsis and septic shock when patients req
uire substantial amounts of crystalloids (weak
recommendation, low quality of evidence).
Why no albumin
白蛋白怎麼來的 !
配合國血國用， since 2007/1
From Toby L. Simon, MD November 5, 2017 PPT
Cost
Cost
Albumin Lactated Ringer
• 1454 元 / 瓶 • 30 元 / 包
Cost
Albumin Lactated Ringer
• 1515 元 / 瓶 • 28 元 / 包
advanced glycation end products (AGEs)
• May result from nonenzymatic glycation reacti

ons
• Animal models show that high-AGE containing
albumin is associated with higher mortality th
an the low-AGE solution
• Unknown in human…
Humpert PM, Lukic IK, Thorpe SR, et al. J Leukoc Biol. 2009;86(3):589-597.
Bar-Or D, Bar-Or R, Rael LT, et al. Crit Care Med. 2005;33(7):1638-1641.
Beneficial Effects of Intravenous Albumin In
fusion on the Hemodynamic and Humoral C
hanges After Total Paracentesis
LUCA et al HEPATOLOGSY September 1995


This study shows that albumin infusion

prevents the impairment in systemic
hemodynamics, vasoactive neurohumoral
systems, and plasma sodium after a large-
volume paracentesis

Albumin Infusion in Patients Undergoing La
rge-Volume Paracentesis: A Meta-Analysis
of Randomized Trials
BERNARDI et al. HEPATOLOGY, April 2012

Albumin Infusion in Patients Undergoing La
rge-Volume Paracentesis: A Meta-Analysis
of Randomized Trials
• This meta analysis provides evidence that albu

min reduces morbidity and mortality among p
atients with tense ascites undergoing large-vol
ume paracentesis, as compared with alternativ
e treatments investigated thus far.

Long term albumin administration improves survival in
patients with decompensated cirrhosis: final results of “
ANSWER” study
• Long-term HA administration improves surviva
l in patients with decompensated cirrhosis, am
eliorates the management of ascites, reduces t
he incidence of severe complications of the dis
ease and the need of hospitalizations, and imp
roves QoL
P. Caraceni, O. Riggio, P. Angeli et al. J. Hepatology 2017, 66, Sup 1, S93

Conclusion
• 白蛋白還是一種藥品或者說是血液製劑
• 對水腫利尿來說，學理上可能有效益，但
還未有大型研究確立證實
• 對休克來說學理上可能有一點效益，但尚
未有大型研究明確證實
• 對於特殊族群的人還是有益處 ( 肝硬化 )

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R3 Topic review

Glick MR, Ryder KW, Jackson SA. Clin Chem 1986;32:470-475

Bakker AJ, Mücke M Clin Chem Lab Med. 2007;45(9):1240-3.

Bianchetti MG, Simonetti GD, Bettinelli A - Ital J Pediatr (2009)

• Furosemide is an organic anion that binds stro

Kidney Int. 1987 Aug;32(2):198-203.

• Double-blind, placebo-controlled study

(a) 60 mg FU plus a sham infusion

• Co-administration of HA increases the natriure

Kidney Int. 1999 Feb;55(2):629-

Group A: diuretics alone (furosemide +

Group B: diuretics + albumin (12.5 g/day)

Group A: diuretics alone (furosemide +

Group B: diuretics + albumin (25 g once a week in the

• Albumin is effective in improving the rate of re

• Albumin is effective in improving the rate of re

Protocol 2: 228000 USD

J Am Soc Nephrol 12: 1010–1016, 2001

J Am Soc Nephrol 12: 1010–1016, 2001

J Am Soc Nephrol 12: 1010–1016, 2001

• In conclusion, our studies have demonstrated

• The cumulative evidence analyzed here does n

Oregon Medical Malpractice and Personal Injury Attorneys http://www.aferetica.com/en/sepsis/

Circulation, Volume 52, September 1975

• Prospective, randomized study

Crit Care Med. 1983;11:839-850.

• No significant differences in any of the hemodynamic meas

• No significant differences in any of the hemodynamic meas

ANESTH ANALG 1985;64:323-6

ANESTH ANALG 1985;64:323-6

N Engl J Med 2004 May 27;350(22):2247-

JAMA November 6, 2013 Volume 310, Number 17

No significant heterogeneity in the effect of treatment on mortality in

n engl j med 370;15 april 10, 2014

n engl j med 370;15 april 10, 2014

n engl j med 370;15 april 10, 2014

Oregon Medical Malpractice and Personal Injury Attorneys http://www.aferetica.com/en/sepsis/

• May result from nonenzymatic glycation reacti

LUCA et al HEPATOLOGSY September 1995

LUCA et al HEPATOLOGSY September 1995

This study shows that albumin infusion

LUCA et al HEPATOLOGSY September 1995

BERNARDI et al. HEPATOLOGY, April 2012

• This meta analysis provides evidence that albu

BERNARDI et al. HEPATOLOGY, April 2012

P. Caraceni, O. Riggio, P. Angeli et al. J. Hepatology 2017, 66, Sup 1, S93

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