Why to use albumin in severe septic shock

Albumin accounts for 80% of colloid osmotic pressure and its domains determine the binding properties for several endogenous molecules and drugs. Moreover plasma albumin concentration is a powerful dose-dependent predictor of mortality. Three metanalysis found albumin administration harmful, neutral and advantageous while the subgroup analysis of SAFE study showed a beneficial trend in septic patients treated with albumin and unfavourable trend in trauma patients with brain injury. For a given reached intravascular volume this effect must be similar for crystalloids, artificial colloids and albumin. Consequently, possible advantages of albumin should be due to a lower complication occurrence and/or to non-oncotic functions. The ALBIOS trial is a multicenter (100 italian ICU) randomized clinical trial on 1818 patients with severe sepsis. Patients randomly received either 20% albumin and crystalloids or crystalloids alone for volume replacement until ICU discharge or 28 days after randomization. Primary outcomes were survival at 28 and 90 days. The addition of albumin to crystalloids during both early volume resuscitation and the first 28 days of treatment to correct hypoalbuminemia is safe, but does not bring forth a survival advantage as compared to the administration of crystalloids alone over a follow-up period of 28 and 90 days. A post-hoc analysis of the 1303 patients with severe septic shock showed a significantly lower 90-day mortality in the Albumin group as compared to the Crystalloid group. Conversely, in patients treated with albumin with severe sepsis without septic shock mortality rate appeared higher although not significantly different. In conclusion, the use of albumin in addition to crystalloids in patients with severe sepsis during early resuscitation and ICU stay to correct hypoalbuminemia does not provide survival benefit at 90 days over the use of crystalloids alone, despite improvements in hemodynamics. The clinical benefit of albumin in the subgroup of patients with septic shock deserves further confirmation.