Albumini – siva zona indikacija

Tamara Murselović, Sanja Berić, Višnja Nesek Adam, Ante Penavić, Vesna Ćosić, Blaženka Miškić

Albumini u modernoj medicini postoje više od osamdeset godina. Prva dokumentirana upotreba u kliničke svrhe opisuje se 1941. godine tijekom napada na Pearl Harbour, kao zamjena za plazmu kod sedmorice mornara s teškim opeklinama.1 Od tada se indikacije za primjenu albumina sve više šire. Već 1950-ih godina udomaćuju se u internoj medicini pri liječenju bolesnika s dekompenziranom cirozom jetre. Međutim, gotovo šest desetljeća nakon upotrebe albumina, jedna metaanaliza 1998. otkriva povećanje smrtnosti kod kritično bolesnih na terapiji albuminima.2 Diskusije i studije, koje se objavljuju već trideset godina, sučeljavaju se s istim problemom: povećavaju li albumini smrtnost u određenim skupinama bolesnika i koje su ispravne indikacije za njihovu primjenu? Prema smjernicama primjena albumina odobrena je za paracentezu bolesnika s cirozom jetre, gdje se odstranjuje veliki volumen ascitesa, kod renalnog zatajenja uslijed razvoja spontanog peritonitisa i hepatorenalnog sindroma te pri plazmaferezi. Albumini imaju pozitivne učinke pri velikim operativnim zahvatima kao što su transplantacije srca, pluća, jetre. U terapiji opeklina, izraženom nefrotskom sindromu, akutnom respiratornom distres sindromu, traumi mozga ili liječenju hipoalbuminemije kao pokazatelja malnutricije nema indikacija za primjenu albumina. Primjena albumina tijekom hemodijalize pokazala se uspješnom i učinkovitom, ali u studijama malih uzoraka.3 Važno su područje upotrebe albumina kritični bolesnici s razvojem sepse i septičkog šoka. Nekoliko velikih studija kao što su studija SAFE i studija ALBIOS provedene su kao metaanalize na velikom broju bolesnika, no nisu pružile kategorički odgovor u prilog smanjenju smrtnosti bolesnika liječenih albuminima kao volumnom nadoknadom u odnosu na kristaloidne tekućine. Cilj je ovog članka pregledom raspoložive literature prikazati preporuke u korištenju albumina u području kliničkog rada s kritično bolesnima u jedinicama intenzivnog liječenja. Literatura je dobivena pretragom baza podataka PubMed i Cochrane. Zaključno, u obilju znanstvenih studija, brojnih čimbenika koji utječu na odluke kliničara i često proturječnih rezultata, primjena albumina u određenim situacijama još uvijek je složena.

Albumins have existed in modern medicine for more than 80 years. The first documented use for clinical purposes was described in 1941 during the attack on Pearl Harbour, as a substitute for plasma in seven sailors with severe burns. Since then, the indications for albumins and their application have been expanding. As early as the 1950s, they were used in internal medicine in the treatment of patients with decompensated cirrhosis of the liver. However, almost six decades after the use of albumin, a meta-analysis in 1998 revealed an increase in mortality in critically ill patients treated with albumins. Discussions and studies, which have been published for
30 years face the same problem: do albumins increase mortality in certain groups of patients and what are the correct indications for their use? The use of albumins according to the guidelines is approved for paracentesis in patients with cirrhosis of the liver, where a large volume of ascites is removed, for renal failure due to the development of spontaneous peritonitis, hepatorenal syndrome and plasmapheresis. Albumins have positive effects during major operations such as heart, lung, and liver transplants. There are no indications for the use of albumins in the treatment of burns, severe nephrotic syndrome, acute respiratory distress syndrome, brain trauma or the treatment of hypoalbuminemia as an indicator of malnutrition. The use of albumins during hemodialysis has been
shown to be successful and effective, but in small sample studies. An important area of use of albumins is critical patients with the development of sepsis and septic shock. Several major studies, such as the SAFE study and the ALBIOS study, were conducted as meta-analyses on a large number of patients, but they did not provide a categorical answer in favor of a reduction in mortality in patients treated with albumins as volume replacement compared to crystalloid fluids. The aim of this article is to review the available literature and present recommendations for the use of albumins in the field of clinical work with critically ill patients in intensive care units. The literature was obtained by searching the PubMed and Cochrane databases. In conclusion, considering the abundance of
scientific studies, numerous factors that influence the decisions of clinicians and often contradictory results, the use of albumins in certain situations is still complex.