Intravenous Albumin: Is it time to consider de-prescribing efforts?

 Abby Wolfe, Knowledge Broker, Canadian Blood Services

Intravenous albumin is a human-derived blood product manufactured from donated plasma. The vast majority of the plasma used to manufacture albumin for Canadian patients is collected outside of Canada. No albumin product is currently manufactured in Canada. It is administered in a wide range of clinical settings with highly variable practice between regions and can be associated with adverse consequences including fluid overload, hypotension, hemodilution requiring red blood cell transfusion and anaphylaxis. Intravenous albumin is also more expensive to manufacture compared to alternatives such as crystalloids, and very few indications have an evidence base that supports its routine use in practice to improve patient outcomes.

Towards the vision of “The right transfusion, always, everywhere”, the International Collaboration for Transfusion Medicine Guidelines (ICTMG) convened an international panel of expert volunteers including researchers, clinicians, methodologists and a patient representative to publish a new guideline on Use of Intravenous Albumin that can inform health-care professionals’ decisions on the use of albumin in its most common clinical settings.  Funding to develop this guideline was provided by the Ontario Regional Blood Coordinating Network (ORBCoN) and the ICTMG, which is supported by Canadian Blood Services.

Published in the peer-reviewed journal, CHEST (2024), this guideline provides actionable and evidence-based recommendations for appropriate use of albumin in adult and pediatric patient populations undergoing cardiovascular surgery, kidney replacement therapy, complications of cirrhosis or critical illness (e.g., intensive care, sepsis). With the completion of a systematic literature review and meta-analysis, guideline recommendations were developed and reported using a rigorous methodology in accordance with Grading of Recommendations Assessment, Development and Evaluation (GRADE), Cochrane risk of bias instrument, AMSTAR, and the AGREE checklist.

Notably, twelve of the fourteen total recommendations do not support routine use of albumin. A commentary on the use of albumin in critically ill patients has also been published in CHEST Physician, including a figure outlining harmful, uncertain, and beneficial clinical settings for albumin use.

• Read the full commentary here:  Use of albumin in critically ill patients | CHEST Physician (mdedge.com). 

Calls for future research identified in the guideline also acknowledge a need for further evidence on dosing strategies with different albumin formulations, adverse reactions from intravenous albumin that can inform conclusions regarding potential risks, and the therapeutic targets of albumin resuscitation.

The guideline is intended primarily to inform critical care physicians, hematologists, transfusion medicine physicians, gastroenterologists, pathologists, nephrologists, hepatologists, anesthesiologists, cardiovascular surgeons, general internists, hospitalists, pharmacists and laboratory technologists, as well as medical trainees, researchers, patients and families.

Following this guideline publication, the ICTMG is undertaking a 1-year knowledge mobilization (KM) project to support the uptake of guideline recommendations into clinical practice by developing and utilizing knowledge mobilization resources, tools, and strategies. To learn more about the progress of this project, visit ICTMG.org/albumin where resources and updates will be posted as they become available. Examples of items undertaken to date include:

• A July 2024 Journal Club webcast presented in partnership with ISBT to review the guideline’s recommendations and evidence which informed the guideline’s development.
• A Breakthroughs in Blood webinar featuring panel discussion hosted by Canadian Blood Services in September 2024 with webinar recording and accompanying Mythbusters resource.
• A podcast episode recorded for the Critical Matters Podcast hosted by Dr. Sergio Zanotti.

Concurrently, ICTMG is also partnering with the Ottawa Hospital Research Institute (OHRI) on an implementation research project to understand the barriers and enablers that influence the uptake of specific guideline recommendations among Canadian health-care providers. To learn more about the guideline, available resources, and the ICTMG’s Knowledge Mobilization and Implementation Research projects, visit the ICTMG website or contact ICTMG directly via info@ictmg.org.

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