What is the role of albumin in hydration and its combination with diuretics, such as furosemide (loop diuretic), to improve urine output in patients with congestion?

From the Guidelines

Albumin should not be used in combination with diuretics to improve urine output in patients with congestion, as the most recent and highest quality study found no difference in urine output at 24 hours and no mortality benefit. The use of albumin in critically ill patients has been extensively studied, and the evidence suggests that it does not provide a significant benefit in terms of mortality or morbidity 1. A 2022 systematic review evaluating the impact of albumin and diuretics, as compared with diuretics alone, in mechanically ventilated patients found that albumin reduced hypotensive episodes, but did not shorten the duration of mechanical ventilation or improve the mortality rate 1. Another systematic review found that albumin with furosemide, compared with furosemide alone, did not increase urine output at 24 hours in patients with hypoalbuminemia and hypervolemia 1.

The typical management of congestion in patients with heart failure involves the use of diuretics, such as furosemide, to increase urine output and reduce fluid overload. The dose of diuretics should be adjusted based on the patient's response, and the goal is to achieve a net weight loss of 0.5 to 1.0 kg per day. The use of albumin in this setting is not supported by the evidence, and it may even increase the risk of adverse effects, such as hypotension and electrolyte imbalances.

Some key points to consider when managing congestion in patients with heart failure include:

• The use of diuretics, such as furosemide, to increase urine output and reduce fluid overload
• The importance of monitoring fluid status, electrolytes, and kidney function to avoid excessive diuresis and dehydration
• The need to adjust the dose of diuretics based on the patient's response
• The goal of achieving a net weight loss of 0.5 to 1.0 kg per day
• The potential risks and benefits of using albumin in combination with diuretics, and the lack of evidence to support its use in this setting.

In terms of specific management strategies, the 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends the use of diuretics to manage congestion, and suggests that the dose of diuretics should be adjusted based on the patient's response 1. The guideline also notes that the use of albumin is not recommended for the management of congestion in patients with heart failure, due to the lack of evidence to support its use.

Overall, the evidence suggests that albumin should not be used in combination with diuretics to improve urine output in patients with congestion, and that the management of congestion should focus on the use of diuretics and careful monitoring of fluid status, electrolytes, and kidney function.

From the FDA Drug Label

Furosemide is extensively bound to plasma proteins, mainly to albumin. Plasma concentrations ranging from 1 to 400 µg/mL are 91 to 99% bound in healthy individuals. Furosemide binding to albumin may be reduced in elderly patients.

The role of albumin in hydration and its combination with diuretics, such as furosemide, to improve urine output in patients with congestion is not directly addressed in the provided drug label. However, it is mentioned that furosemide is extensively bound to albumin, and this binding may be reduced in elderly patients 2.

• The label does not provide information on the use of albumin in hydration or its combination with diuretics to improve urine output.
• It only discusses the pharmacokinetics and pharmacodynamics of furosemide.
• Therefore, no conclusion can be drawn about the role of albumin in this context based on the provided information.

From the Research

Role of Albumin in Hydration

• Albumin plays a crucial role in maintaining fluid balance and hydration in the body, particularly in patients with hypoalbuminemia 3, 4.
• Hypoalbuminemia is a major cause of diuretic resistance, and albumin mixed with furosemide can promote diuresis and sodium excretion in patients with hypoalbuminemia 3.

Combination of Albumin with Diuretics

• The combination of albumin with diuretics, such as furosemide, has been shown to enhance diuresis and improve urine output in patients with congestion 3, 5, 6.
• Studies have demonstrated that the co-administration of albumin and furosemide can increase urine volume and sodium excretion in patients with hypoalbuminemia 3, 5, 6.
• However, the effectiveness of this combination may vary depending on the patient's renal function and the severity of hypoalbuminemia 3, 7.

Clinical Evidence

• A randomized controlled study found that the combination of furosemide and albumin had a superior short-term efficacy over furosemide alone in enhancing water and sodium diuresis in hypoalbuminemic chronic kidney disease patients 6.
• A meta-analysis of clinical studies found that the co-administration of albumin and loop diuretics resulted in a statistically significant increase in urine volume and sodium excretion in hypoalbuminemic patients 5.
• However, another study found that albumin failed to enhance the diuretic effects of furosemide in cirrhotic patients with ascites 7.

Potential Benefits and Limitations

• The use of albumin in combination with diuretics may offer potential benefits in improving urine output and reducing fluid overload in patients with congestion 3, 4.
• However, the clinical evidence is not uniform, and more studies are needed to establish the effectiveness and safety of this combination in different patient populations 7, 5, 4.