The influence of the use of human albumin on morbidity/mortality and the costs of hospitalization of critically ill patients
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KeywordsStarch Albumin Mechanical Ventilation Acute Renal Failure Liver Failure
Human albumin has been used in the clinical practice for more than 40 years, and its use was stimulated by several studies that showed inverse correlation between serum albumin and mortality . However, a meta-analysis published in 1998  radically modified that line of reasoning by demonstrating that the use of albumin solutions to expand volemia and to correct hypo-albuminaemia was associated with an increase in the mortality rate in critically ill patients.
To compare two groups of patients admitted to a general ICU to determine the influence of the accentuated reduction in the use of human albumin to correct hypovolemia and hypoalbuminaemia on the morbidity/mortality and costs of hospitalization.
We included in the study all patients with a length of stay of at least 48 h in a 13-bed general ICU in two periods of 5 months. Group I comprised 137 patients admitted in the period from 1 March to 31 July 31 1998. During this period the main fluid for volemic replacement was 5% human albumin and almost all the patients with albuminemia below 3.0 g% received 20% albumin solution, 20 g/day. Group II comprised 131 patients admitted in the period from 1 March to 31 July 1999. In this period the main fluid for volemic replacement was 6% hydroxyethyl starch, and few patients (burned, liver failure) received albumin solution to correct hypoalbuminaemia. The two groups were compared as to the mortality, ICU stay, duration of mechanical ventilation, incidence of nosocomial pneumonia, acute renal failure and costs of the hospitalization.
The two groups were comparable in relation to age, sex and APACHEIII score. The incidence of renal dysfunction at the ICU arrival was significantly more elevated in the group I (P < 0.05). Sixty-seven (48.9%) of the 137 patients of group I and 13 (9.9%) of the 131 patients of the group II used albumin (P < 0.001). There was no significant difference between the two groups in relation to mortality, ICU stay, duration of mechanical ventilation and incidence of nosocomial pneumonia. The overall cost of hospitalization for the patients from group I was $;US11,364.73 ± 14,787.19, while in group II it was $US6,712.50 ± 9,922.50 (P < 0.01).
The Cochrane Institute meta-analysis comparing the use versus no use of human albumin in critically ill patients to restore volemia or to treat hypoalbuminaemia and that concluded that there was an increase in the mortality rate within the patients that used albumin, radically modified albumin consumption. Roberts et al.  analyzed the consumption of human albumin in the UK in the period extending from January 1993 to December 1998. In Scotland, the consumption that used to be stable, dropped 65% starting from July 1998. In the remainder of the UK the fall was of 45%.
In our Service, comparing two periods of 5 months, before and after the publication of the meta-analysis, the reduction in the consumption of human albumin was of 80%. Furthermore, it was not observed mortality or morbidity difference concerning this approach change. The costs of hospitalization, however, were considerably reduced with the restriction of albumin use.
If we consider the elevation of the costs of the treatment when albumin is used, compared to other plasmatic expansors, the nonexistence of differences in the morbidity/mortality is already a strong argument in favor of the substitution of albumin for volemic expansion of critically ill patients, and to use an approach based on a precocious and well-designed nutritional support to correct hypoalbuminemia.