Human albumin for hypotension in haemodialysis patients

Intradialytic hypotension (IDH), which is caused by a decrease in blood volume, is a common complication of haemodialysis treatment. It is characterized by a sudden drop in blood pressure with symptoms of nausea, sweating, cramping, or dizziness and causes much discomfort to the patient. IDH is managed by giving fluids to the patient. These can include saline, albumin or other fluids such as gelatins and starches. Because albumin is a relatively rare and expensive blood product, we asked if albumin had an advantage over other fluids to treat IDH. We found one trial comparing albumin to normal saline; no trials were found comparing albumin to other fluids used to treat hypotension. This trial showed no difference between albumin and normal saline in all outcomes except for the amount of additional saline given, which was less in the group treated with albumin. We concluded that normal saline should be the first choice for treating IDH.

Authors' conclusions: 

No randomised or controlled trial was identified comparing albumin to crystalloids (other than normal saline) or non-protein colloids, or a combination of both, in the treatment of symptomatic hypotension during dialysis. One double blind crossover RCT in 45 assessable patients showed that 5% albumin is not superior to normal saline for the treatment of symptomatic hypotension in maintenance haemodialysis patients with a previous history of IDH. Given the cost and relative rarity of albumin use compared to saline, saline should be first line of therapy for treatment of IDH in stable dialysis patients.

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Background: 

Intradialytic hypotension (IDH) occurs in 20% to 55% of haemodialysis sessions and is more frequent among patients on long-term haemodialysis. Symptomatic IDH is generally defined as a decrease in systolic blood pressure (BP) of at least 10 mm Hg or a systolic BP less than 100 mm Hg, with symptoms such as cramps, nausea, vomiting, and dizziness. IDH is managed acutely by volume expansion through the intravenous administration of fluids.

Objectives: 

To compare the benefits and harms of volume expansion with human albumin, alone or in combination with crystalloid or non-protein colloids, for treating IDH in haemodialysis patients.

Search strategy: 

The Cochrane Renal Group's Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 9) MEDLINE (1966 to Oct 2009), and EMBASE (1980 to Oct 2009) were searched.

Selection criteria: 

Randomised controlled trials (RCTs), quasi-RCTs as well as randomised crossover studies were to be included.

Data collection and analysis: 

Two authors independently extracted data and assessed trial quality. Relative risk (RR) was to be used to analyse dichotomous variables and mean difference (MD) used to analyse continuous variables.

Main results: 

One double blind randomised crossover trial met the inclusion criteria and compared 5% albumin to normal saline in patients with a previous history of IDH. Results from 45 assessable participants did not lead to rejection of the null hypothesis of no difference between 5% albumin and normal saline in the primary outcome measure of percentage target ultrafiltration achieved, nor in 11/12 secondary outcomes. Additional (unblinded) saline was given less often when 5% albumin was used compared with saline (16% versus 36%, P = 0.04). However, the volume of additional fluid administered was similar in both groups. There were no significant differences in the nursing time required to treat IDH and the time to restore BP.

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