Hi. I'm Janine Knudson. And I'm Steve Lieu. Today, we're gonna talk about the most common protein in the body. Can you guess what it is?
Here's a clue that actually probably won't help anybody. According to a study from 2,012, it has commonality between us, bovines, equines, leperines. What's that? A leopard? Isn't it obvious, Janine?
No. Not really, Steve. Yeah. Fair enough. I I actually have to look that up.
So it's really just a fancy name for a hair. Teaching point number 1, I guess. So this underappreciated molecule remains, by and large, to the medical community, kinda pointless. Unless, of course, your patient is a cirrhotic. Then it makes all the difference.
So let's do the big reveal. We'll be covering, drum roll, please, albumin. Our question number 1 is, how much albumin do you give for a patient with SBP and why? And number 2, what antibiotics do you use for SBP? And number 3, do you always have to use albumin?
So let's go deeper into the wonderful world of albumin and see how and if it's truly useful. You're listening to Mind the Gap. I'm Janine Knudson. And I'm Steve Lieu. Today, we're gonna be talking mainly about albumin.
We'd like to thank doctor Renee Williams, gastroenterologist at NYU, for peer reviewing this episode. This is a Core I'm podcast supported by clinical correlations. In today's episode, we're gonna focus on the data for the utilization of albumin and cirrhotics, specifically in spontaneous bacterial peritonitis. And so you've probably heard that you give 1 and a half grams per kilogram on day 1 and then 1 gram per kilogram on day 3. But where do those actually strange and kinda arbitrary numbers come from?
And do you always have to do that? So to give some context, remember from our last episode that people studying spontaneous bacterial peritonitis, or SBP, in the 19 eighties were noting incredibly high death rates. As high as 40 to 50% in some studies. So compare that to pneumonia. Even the worst kind of pneumonia hasn't had a case mortality rate of over 20% in the last decade.
So what's the idea? Did they not know how to use cephalosporins? 3rd generation cephalosporins have been around for 40 years. Let's trace to the history here. Since the eighties, we've known that using 3rd generation cephalosporins like cephataxime improved what we called cure rates, which is when you repeated the tap on day 3.
Which, by the way, they do not recommend doing anymore. But what's interesting is that better antibiotics didn't change mortality. And other attempts to change antibiotic frequency and duration, both continued to fail showing any improvements in mortality. They tried changing the duration of treatment, increasing the dose. No luck.
So by the late nineties, antibiotics are pretty much beaten to death. As it turns out, these folks weren't really dying of infections per se. The real problem was actually renal failure. So here's what happened next. A group of hepatologists at the University of Barcelona and I'm probably gonna need your help here, Janine.
Okay. Let me give it a shot. Yeah. Pau Sort, Vicente Arroyo, and Perjinae. Thanks for the assistance there.
I tried. These guys were clearly super interested in the kidney and the renin aldo angiotensin system, at least based on their publications. I I don't really know any of these guys personally. But, really, if you PubMed their names, they have dozens of articles on the kidney system and cirrhotics. And these are a bunch of hepatologists getting excited about the kidneys.
It's literally the least GI organ of all time. So the the thing was that their patients were dying of SPP, but like I mentioned, they they were dying of the dreaded hepatorenal syndrome. So they got together and discovered a use for GI's most beloved medication besides lactulose. And that turned out to be albumin. Yeah.
Literally nobody else likes this stuff. Yeah. The the ICU, Poem Creek Care folks, they shot it down in the safe trial, and now Cochrane doesn't even recommend its use for resuscitation. Unless, of course, your patient has SBP and is a cirrhotic. So this comes from the descriptively named study, the effects of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.
That's a mouthful. I know. You know how we can tell that this comes from the beginning of trial driven evidence based medicine? How's that, Janine? I mean, it's probably the worst title ever of all time.
Sure. It's informative, but is it easy to cite? Not at all. How many big words did they string together? They should have figured out a way to call it the albumen trial.
Always looking big picture, Just saying. That's probably why everyone calls it the SORT trial. So besides the title, what did it show? Well, it actually did show a reduction not only in renal failure, but also in that big ticket item, mortality. Okay.
So what we're talking about here is absolute risk reductions of 23% in renal failure and 19% in mortality. This corresponds with numbers needed to treat a 4 and 5 respectively. Yeah. And we only found one issue with this trial, which is that it's pretty small. They only had 60 patients in each group.
Okay. But their results were statistically significant, so we're gonna take them at least as being somewhat positive. We finally have a therapy that's not only gonna drastically reduce renal failure and mortality And we've brought down mortality to that of pneumonia. Which I guess is good. But what about those weird doses of albumin?
So this next story is completely anecdotal, so take it as you will. One time, I was told by a senior hepatologist who, I guess, kinda sorta ran into doctor Sort at a hepatology conference, and they got to chatting about the protocol, because it's not actually explained in the primary article why they used so much albumin. Yeah. As a reminder, they're giving 1.5 grams per kilogram to an average American male who, let's say, weighs 60 kilograms. Actually, it's closer to 75.
What? Absolutely not. I just Googled it. Okay. So so that's what?
A 112 grams or 9 bottles of albumin? Right. And that that's actually kind of a lot. And so sort answered that they chose a really high number mainly because they wanted to make sure they saw an effect. So you're telling me it's kind of arbitrary?
To an extent, yes. I'm sure they had a physiologic reason, but medicine is also an art, isn't it? Yeah. Okay. And for what it's worth, the last paragraph of their article does note that, quote, intravenous albumin is expensive.
Therefore, studies should be performed to determine whether lower doses of albumin would have similar beneficial effects on renal function and survival. Were those ever done then? Of course not. Of course not. But still, that ends up being a lot of albumin.
And, you know, it's kind of funny. Not funny More like funny, oh, I have no idea how to compare albumin and crystalloid. Yeah. There's a couple of citations we found that suggest that 5% albumin is about equivalent to 4 times its weight in crystalloid. To contextualize that, one unit of albumin is 12 and a half grams.
So that means 5% is 12.5 grams diluted into a 250 cc bag, whereas 25% albumin is mixed into 50 cc's. Wait. So that math Didn't you go to MIT, Steve? That was a long time ago. I I need to concentrate.
Okay. Okay. Help me out. Okay. Okay.
Let me help you out. So using that 4 times calculation, one unit of 5% albumin is approximately 1 liter of crystalloid, give or take. Oh, why give or take? Because I'm not a pharmacologist, and if you really hunt down how they came up with that 4 times figure, they don't give any citation for that statement. In fact, there's a 1998 review titled albumin, not all it was cracked up to be, where it says without any real citation, 4.5% albumin is approximately 4 times as effective in expanding plasma volume as sodium containing crystalloids.
Didn't you mention the SAFE trial about ICU resuscitation? Yeah. And they admit, and I quote, albumin and saline are not considered equipotent intravascular volume expanders, but their relative potencies have not previously been examined in an adequately powered blinded trial. So if you buy into this number, even without a citation, we have a conversion rate of 1 unit albumin to 1 liter crystalloid. Okay.
So I'm gonna try this here. So if that's the case, we think about a 50 kilogram person. They need 75 grams of albumin. So you're giving a person that weighs barely a £120 the equivalent of 6 liters of fluid. Woah.
Yeah. I guess in context, you give 30 cc's per kilogram here at Bellevue, and that's only 1 and a half liters. Woah. Okay. There was one last point we wanted to make.
Do you always have to use albumin? In an article published in PostScript, the letter sections of the journal Gut, there are some authors that suggested you don't. And, yes, before you ask, this citation is actually used by the AASLD. Wait. Really?
Yeah. Anyway, so this is a group at Mount Sinai in New York, and the folks from the original trial, from Barcelona, they kinda collaborated here. And they went through the data, and they found patients with elevated billies, BUN or creatinine, seem to benefit the most. Yeah. They developed a protocol to give albumin only to those with billies greater than 4, BUN greater than 30, or creatinine greater than 1.
And those are all in milligrams per deciliter. And they found that the low risk group did well without albumin, and hardly anybody developed renal failure, and nobody died. And they found that the high risk groups did reasonably compared to the data seen in the SORT trial. 90% died, 15% had renal failure. But watch out.
There's no control group here. So maybe we shouldn't give albumin to our less sick patients? Well, it's kinda tough because we have a gold standard of care, and there's not likely to be any motivation for clinicians to do something potentially risky for their really sick patients. So it's kind of an impasse then. Well, yeah, to a degree, but the key point to take away here is that albumin is useful, especially in cirrhotics.
And, you know, there are actually some great articles to explain why, but there is conclusive evidence to say that at this specific dose for SPP, we have a huge benefit in terms of renal failure and mortality to our patients. And that alone is enough to say thanks to albumin, our favorite molecule. So let's recap. Number 1, cephalosporins are good for SVP. Number 2.
Preventing hepatorenal syndrome is important, and you can do with albumin. And number 3. The dose of albumin we give is random, but that's okay. Some intrepid doctor, maybe one of you guys, will be studying this in the future. No.
They absolutely won't. Okay. Fine. See, be a downer. So we know that we went kinda quickly through the data.
And arguably not as in-depth as some might like. So as always, we wanna encourage you to check out the data too. Take a look at the links below the podcast on the Clinical Correlations website so you can take the time to judge the data for yourself and sound smart on rounds. Super smart. Super smart.
After all, this is a podcast talking about those gaps in our knowledge because you only heard it the one time. So if you really wanna feel confident on the data, take the time to pick it apart yourself. And if there are any other topics you'd like to hear discussed, please let us know. I'm Steve Lu. And I'm Janine Knudson.
And remember, mind the gap. Thanks for listening. Disclaimer. Opinions in this podcast are our own and do not represent the opinions of NYU or other affiliated institutions. Please don't use this podcast for medical advice, but instead consult with your health care provider.
How are you not hearing this beeping? No. But I wanna take out this annoying beeping noise. So Janine has a beeping voice in her head. I think she's a robot.
It's gone. It's gone? It's in the headset. It's not in the headset. Who the hell?
You sound like a crappy Zoolander right now.
CORE IM Albumin Inservce Albumin Inservice Lance Cho Powerpoint
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