ICTMG knowledge mobilization activities promote appropriate use of albumin

Albumin is the most abundant protein found in human plasma. Intravenous albumin is a therapeutic product used in a variety of clinical settings for both pediatric and adult patients. As with any blood product, its use should be carefully stewarded to optimize patient outcomes, preserve blood bank resources, and minimize potential harms.

In 2024, the International Collaboration for Transfusion Medicine Guidelines (ICTMG) – a collaborative of expert volunteers around the globe whose secretariat is hosted by Canadian Blood Services – published a new clinical guideline offering evidence-based recommendations for the use of intravenous albumin.

This blog summarizes a selection of the knowledge mobilization activities undertaken since the guideline’s publication to support awareness and uptake of its recommendations into practice.

Comments have been provided by:

• Dr. Jeannie Callum, lead author of the ICTMG’s Use of Intravenous Albumin guideline and clinical lead for the ICTMG's Albumin Knowledge Mobilization (KM) Project; 
• Dr. Nicole Relke, transfusion medicine fellow, University of Toronto and Canadian Blood Services and ICTMG project member; 
• Dr. Sheharyar Raza, transfusion medicine specialist and ICTMG project member;
• Erica Seelemann & Kaylee Brooks, members of Canadian Blood Services knowledge mobilization & strategic alliances team. 

What do you think is important for patients to know about albumin?  

• Dr. Raza: Whether a patient receives albumin varies widely, and depends on the physician, hospital, and country you might be in, rather than your medical circumstance. This reflects the paucity of evidence for its use. While some patients may benefit from albumin, others may incur harms. It is important to ask your physician why they are recommending albumin treatment, and whether there is evidence to support to support transfusion for patients like you.  

• Dr. Callum: Given the lack of evidence to support the use of albumin in most settings, a shared decision-making process between the patient and their clinical team should be used before embarking on the use of albumin. 

What do you think is important for health care professionals to know about albumin?  

• Dr. Raza: The new albumin guideline has demonstrated that many of our presuppositions about how albumin should be used, which may be picked up from training or local practice norms, are simply not supported by a credible body of evidence. This is particularly true for 5% albumin and its use outside plasma exchange, and largely true for 25% albumin. In the absence of established benefit, we must weigh medical and societal harms of albumin use. 

What changes in practice does the ICTMG’s Use of Intravenous Albumin guideline call for, and who would be most affected by those changes?  

• Dr. Relke: The guideline emphasizes that albumin should not be used routinely across most indications where it is commonly used due to lack of demonstrated benefit, higher cost compared to alternatives, and risks including fluid overload and pulmonary edema.  
  
  This includes the following:  

  • Critical care (adult, pediatric, neonatal) where crystalloids remain the first-line fluid choice for volume resuscitation.
  • Kidney replacement therapy, where there is a lack of evidence to support superiority over less costly fluid alternatives.
  • Cardiovascular surgery, where albumin use for both pump prime and fluid resuscitation increased rates of bleeding, resternotomy and infection; and in patients with pre-operative kidney dysfunction, a higher rate of post-operative kidney failure. 
  • Cirrhosis, where albumin use is not routinely recommended outside of the two accepted indications described below (spontaneous bacterial peritonitis and large volume paracentesis). 
    
    These recommendations span the entire hospital, from pediatric NICU to the adult operating room, and will affect many health care professional roles. Intensivists, nephrologists, anesthesiologists, surgeons, internists, and gastroenterologists will need to adjust their personal prescribing practices and work to change practice at their local hospital. Transfusion medicine specialists, who often oversees albumin prescribing especially in larger hospitals, can help clinical teams align their practice with evidence-based recommendations. 

In what circumstances does the guideline acknowledge albumin could be appropriate to use? 

• Dr. Relke: The guideline reviewed 14 recommendations on intravenous albumin use, and only two supported the use of 25% albumin (20% albumin in some regions internationally), both in patients with cirrhosis. The first is in those with spontaneous bacterial peritonitis (SBP), where albumin is suggested to reduce mortality. The second is in patients with cirrhosis and transudative ascites undergoing large-volume (>5L) paracentesis (LVP), where albumin is suggested to prevent paracentesis-induced circulatory dysfunction.  
  
  Note: LVP in patients with malignancy and exudative ascites do not benefit from the infusion of peri-procedure albumin. It is also worth noting that the use of albumin for therapeutic apheresis was excluded from this guideline, as separate, recent apheresis guidelines already recommend 5% albumin as an appropriate replacement fluid in that setting. 

How have ICTMG and Canadian Blood Services supported knowledge mobilization for this guideline?  

• Dr. Callum: When any ICTMG guideline is developed, a KM Project is convened to support efforts to connect the guideline to its target audience and develop resources to help to align the science with the clinical practice.
  
  For the Albumin KM Project, launched in September 2024, a small team of expert volunteers collaborated to:  

  • Secure endorsement from Canadian and international organizations including the National Advisory Committee on Blood and Blood Products, the Società Italiana di Medicina Interna, and the International Society for Blood Transfusion (ISBT); 
  • Feature the guideline in an ISBT-partnered Journal Club webcast with 77 attendees from around the world and over 1300 recording views;  
  • Complete oral and poster presentations at transfusion medicine conferences and other professional education events; 
  • Implement and publish successful quality improvement projects where hospitals successfully aligned practice with the guideline; 
  • Discuss the guideline’s recommendations for critical care settings on a podcast; and, 
  • Author additional articles and publish commentaries and editorials about the use of albumin in specific clinical settings. 
     

• Erica: Canadian Blood Services supports the mobilization of research into clinical practice through many initiatives, ensuring that impactful research gets to the right audiences. As part of this work, Chapter 3: Albumin in the Clinical Guide to Transfusion underwent a comprehensive update to include the latest research – which included the ICTMG’s Use of Intravenous Albumin guideline. Thanks to coordinated efforts to share the updated chapter with knowledge users, it was viewed 1,924 times in its first month of publication!  

• Kaylee: A Breakthroughs in blood: Advancements in action webinar also provided opportunity for a panel of experts to discuss the guideline in September 2024. This webinar, which is part of an ongoing series hosted by Dr. Callum and coordinated by Canadian Blood Services, reached 135 attendees with panelists from around the globe. Resources developed to accompany the webinar include a set of Q&A’s addressing common myths about intravenous albumin and encouraging evidence-based decisions regarding its use.  

What kinds of future research is needed to answer remaining questions about albumin use? 

• Dr. Raza: We need studies of patient and plasma donor perspectives, large scale high-quality prospective and retrospective studies, and clinical trials of albumin use, to identify, understand, and close important gaps in our knowledge of how albumin should be used. As albumin use continues to grow rapidly worldwide, these studies are urgently needed to mitigate shortages of this scarce manufactured blood product. 

Canadian Blood Services – Driving world-class innovation  

Through discovery, development and applied research, Canadian Blood Services drives world-class innovation in blood transfusion, cellular therapy and transplantation—bringing clarity and insight to an increasingly complex healthcare future. Our dedicated research team and extended network of partners engage in exploratory and applied research to create new knowledge, inform and enhance best practices, contribute to the development of new services and technologies, and build capacity through training and collaboration. Find out more about our research impact. 

The opinions reflected in this post are those of the author and do not necessarily reflect the opinions of Canadian Blood Services nor do they reflect the views of Health Canada or any other funding agency.