with buffered drug formulations administered to patients with normal liver function . 6
In vitro , albumin has shown apoptosis inhibitory activity in cultured endothelial cells and anticoagulant and anti-thrombotic properties through the neutralisation of coagulation factor Xa and inhibition of platelet function . 1 Moreover , in a small study of patients undergoing coronary bypass , albumin was capable of preventing erythrocyte crenation induced by free fatty acids , which is thought to cause impaired microcirculatory flow and tissue oxygenation in the intra and post-operatory periods . 7 In another study using endothelial and renal cell models , albumin prevented increased endothelial cell permeability induced by heparinbinding protein . In addition , patients with septic shock who developed or suffered a worsening of acute kidney injury showed a higher ratio of heparin-binding protein to albumin , as well as increased heparin-binding protein levels , than those patients without kidney injury . 8
Other functions for albumin have been revealed recently . The protein can potentially prevent the degradation of the layer of glycoproteins present on the surface of vascular endothelial cells ( the glycocalyx ) that occurs during sepsis . This structure controls vascular permeability and microvascular tone and regulates leukocyte adhesion , and its integrity may be compromised by the conventional fluids used in resuscitation . However , albumin showed to be more protective of glycocalyx than hydroxyethyl starch and normal saline solution in animal heart models , as reflected by an improved vascular filtration . 9 Other non-oncotic features of albumin include anti-inflammatory properties through binding to pro-inflammatory substances such as bacterial lipopolysaccharide and peptidoglycans . Systemic
inflammation in sepsis is mediated by cytokines and reactive oxygen and nitrogen species generated by neutrophils , macrophages , and endothelial cells , and albumin constitutes the main contributor in the response against oxidative stress . Albumin can also counteract , via reversible binding , the immunosuppressive effects of prostaglandin E2 in acutely decompensated liver cirrhosis , which is associated with systemic inflammation . 5 Albumin appears to have an important role in immunomodulation as well , through regulation of nuclear factor-kappa B activation , induction of gene expression of tumour necrosis factor-alpha , and induction of T-cell activation , which may potentially influence the inflammatory and immune response
10 , 11 during critical illness .
Clinical uses of albumin One of the first reports of clinical use of albumin was as a plasma expander during World War II . Shortly after , it was applied to manage ascites in decompensated liver cirrhosis , which features an inadequate supply of amino acids and energy as well as reduced albumin synthesis . Albumin infusion increases cardiac output and vascular resistance by expanding plasma volume and increasing cardiac preload and output while inducing arterial vasoconstriction , which is not seen with synthetic volume expanders such as dextran and gelatin . It is , therefore , used to prevent circulatory dysfunction following therapeutic paracentesis or acute bacterial infections , as well as hepatorenal syndrome in patients with decompensated liver cirrhosis . Volume expansion with albumin solution , together with administration of vasopressors , is currently the standard of care for patients with acute kidney injury due to hepatorenal syndrome ( Table 1 ). 4 , 5 Hypoalbuminaemia is defined by a serum
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