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The role of albumin physiology in critically ill patients, and the pros and cons for administering albumin to hypoalbuminemic patients, have recently been discussed.85 Results of the Saline vs. Albumin Fluid Evaluation (SAFE) study, a RCT comparing 4% human albumin in 0.9% saline with isotonic saline in ICU patients, seem to indicate that albumin is safe, albeit no more effective than isotonic saline (the standard of care choice of isotonic sodium chloride in most centers) for fluid resuscitation. SAFE demonstrated further no difference in renal outcomes, at least based on the need for and duration of RRT.86 The SAFE study was a double-blind study and it was noted that patients in the albumin arm received 27% less study fluid compared to the saline arm (2247 vs. 3096 ml) and were approximately 1 l less positive in overall fluid balance.86 Furthermore, very few patients in the trial received large volume fluid resuscitation ( > 5 l) and thus the results may not be applicable to all patients. The Work Group noted that while isotonic crystalloids may be appropriate for initial management of intravascular fluid deficits, colloids may still have a role in patients requiring additional fluid.
Figure 8 | Conceptual model for development and clinical course of AKI. The concept of AKI includes both volumeresponsive and volume-unresponsive conditions. These conditions are not mutually exclusive, and a given patient may progress from one to the other. Time runs along the x-axis, and the figure depicts a closing ‘‘therapeutic window’’ as injury evolves and kidney function worsens. Biomarkers of injury and function will begin to manifest as the condition worsens, but traditional markers of function (e.g., urea nitrogen and creatinine) will lag behind hypothetical ‘‘sensitive’’ markers of kidney injury. Mortality increases as kidney function declines. AKI, acute kidney injury. Reproduced from Himmelfarb J, Joannidis M, Molitoris B, et al. Evaluation and initial management of acute kidney injury. Clin J Am Soc Nephrol 2008; 3: 962–967 with permission from American Society of Nephrology82 conveyed through Copyright Clearance Center, Inc; accessed http://cjasn.asnjournals.org/content/3/4/962.long
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