Use Of Albumin And Diuretics For Edema Treatment

Although the combination of albumin and diuretics has been used in the treatment of nephrotic edema for over 25 years, few studies have critically examined the response to this therapy. Most studies report using 0.5-1.0 g/kg body weight of 20-25% albumin administered over 30-60 min followed by a 30-min infusion of 1-2 mg/kg furosemide. This therapy is then repeated daily or every other day as needed to achieve the desired degree of weight loss. Average weight losses of 1.2 to 2.5% of the initial pretreatment body weight have been reported in children responding to this regimen. Unfortunately, not all nephrotics respond to this treatment and it is not possible to predict who will respond based on renal histology, initial serum albumin concentrations, or other parameters. Additionally, it is difficult to ascertain how much greater a response will be obtained using the combination of albumin and loop diuretic compared to the diuretic alone. McLigeyo reported an average increase in urine volume of 874 ml/24 hr in 11 nephrotics following addition of 200 ml of 25% albumin solution to a regimen of furosemide and spironolactone [11]. A 59% improvement in sodium excretion rate and an 87% increase in total urinary furosemide excretion rate has been reported following addition of 20-25 g of albumin to 1 mg/kg body weight dose of furosemide injected into nephrotics with initial serum albumin values of less than 2.0 g/dl [9], On the other hand, Akcicekand associates in a randomized cross-over study of eight nephrotics with average serum albumin concentration of 1.73 mg/dl found no potentiation of diuretic or natriuretic response with the combination of 0.5 g/kg albumin and furosemide compared to furosemide alone [1]. The albumin infusion did, however, produce a 30% increase in plasma volume (see Fig. 2). Combining several diuretics with different sites of action and albumin has been reported to induce no greater sodium excretion than administration of albumin with a loop diuretic. Even in those responding to diuretic and albumin therapy, intense sodium retention occurs rapidly after therapy is discontinued unless remission of the underlying glomerular disease is achieved.

Very little information is available on the use of albumin and diuretics for the edema associated with cirrhosis and other hypoproteinemic conditions. In cirrhosis this undoubtedly reflects the recognition that rapid diuresis is unnecessary and potentially hazardous due to the limited rate at which fluid can be reabsorbed from the peritoneal cavity. Furthermore, in circumstances where fluid must be removed rapidly, large volume paracentesis has been reported to be more effective and have fewer complications than diuretic therapy [13]. Thus this latter technique has been used instead of diuretics when vigorous fluid and sodium removal is required. Other hypoproteinemic diuretic resistant conditions do not occur with sufficient frequency to determine whether diuretics combined with albumin are beneficial.

FIGURE 2. Effect of furosemide and albumin alone and in combination on urinary sodium excretion rate in 12 patients with nephrotic syndrome. The addition of albumin to furosemide had no additional effect on sodium excretion compared to that seen with furosemide alone. Adapted from Akcicek (1995, p 162) with permission.

FIGURE 2. Effect of furosemide and albumin alone and in combination on urinary sodium excretion rate in 12 patients with nephrotic syndrome. The addition of albumin to furosemide had no additional effect on sodium excretion compared to that seen with furosemide alone. Adapted from Akcicek (1995, p 162) with permission.

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