国内著名专家黎介寿发现严重感染的危重病人,白蛋白水平大于35g/l,死亡率为0;而白蛋白水平小于20g/l时,死亡率高达54%。一项大型荟萃分析,包括90个分析低蛋白血症对预后的预测性的队列研究 (n=291,433) 和9个研究纠正低蛋白血症治疗的前瞻性对照试验 (n=535)发现,低蛋白血症患者白蛋白水平每降低10g/l,其死亡率增加137%,并发症发生率增加89%,ICU停留时间延长28%,住院时间延长71%,治疗费用增加66%,文章认为低白蛋白血症是增加危重患者死亡率和并发症的独立危险因素,给予外源性白蛋白需达到血浆白蛋白浓度达到30g/L以上,显著减少并发症发生率。79项随机试验,荟萃分析了使用白蛋白与使用晶体、人工胶体、不使用白蛋白或小剂量白蛋白比较的随机对照试验,共4755例患者,其中59项(占79项的74.7%)试验的治疗结果有显著性差异,认为使用白蛋白带来了临床获益。发现低白蛋白血症患者中,大剂量的白蛋白可减少死亡率,说明在不同的临床领域,使用白蛋白可带来临床获益。所以对于低蛋白血症患者,只要临床觉得有使用必要,就不应该限制使用。5:白蛋白产品安全性因为白蛋白是人体天然的产物,所以其产生的不良反应较各种人工胶体来得低,参考白蛋白和其他胶体液用于扩容的安全性的比较(表2)。白蛋白的急性反应事件和威胁生命的严重不良事件均是最少的。表2.白蛋白和其他胶体液用于扩容的安全性的比较10家全球主要白蛋白供应商在1998年-2000年总共向市场供应648,000,000克白蛋白,一共收到198个非致命性不良事件和13个致命性不良事件报道。若以40克为一次处方剂量,那么分析显示:每1000,000次处方中非致命性不良反应的发生率是4.65,致命性不良反应的发生率是0.185。结论显示:人血白蛋白具有非常好的安全记录。6:使用白蛋白的经济性因为白蛋白可以减少并发症的发生率,同时可以缩短ICU停留时间和住院时间,保护凝血功能等,所以整个疗程价格反而是更加经济的。一项美国的研究,统计了5156名脓毒症患者,发现使用白蛋白每个生命可以节约6037欧元,而每年每人可以节约617欧元。对美国较大医院的数据库的出院数据进行回顾性分析,19,578个冠脉搭桥术患者在操作中应用了胶体,使用白蛋白组死亡率为2.47%,低于非蛋白胶体组的3.03%,应用白蛋白,每个生命可节省52,000-54,000美元参考文献 Quinlan GJ, Martin GS, Evans TW. Albumin: biochemical properties and therapeutic potential. Hepatology. 2005. 41(6): 1211-9. McClelland DB. ABC of transfusion. Human albumin solutions. BMJ. 1990. 300(6716): 35-7. Dubniks M, Persson J, Grande PO. Plasma volume expansion of 5% albumin, 4% gelatin, 6% HES 130/0.4, and normal saline under increased microvascular permeability in the rat. Intensive Care Med. 2007. 33(2): 293-9. Wilkes MM, Navickis RJ, Sibbald WJ. Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding. Ann Thorac Surg. 2001. 72(2): 527-33; discussion 534. Palanzo DA, Zarro DL, Montesano RM, Manley NJ. Albumin in the cardiopulmonary bypass prime: how little is enough. Perfusion. 1999. 14(3): 167-72. Blanloeil Y, Trossaert M, Rigal JC, Rozec B. [Effects of plasma substitutes on hemostasis]. Ann Fr Anesth Reanim. 2002. 21(8): 648-67. Haddad JJ. Oxygen homeostasis, thiol equilibrium and redox regulation of signalling transcription factors in the alveolar epithelium. Cell Signal. 2002. 14(10): 799-810. Alam HB, Stanton K, Koustova E, Burris D, Rich N, Rhee P. Effect of different resuscitation strategies on neutrophil activation in a swine model of hemorrhagic shock. Resuscitation. 2004. 60(1): 91-9. Powers KA, Kapus A, Khadaroo RG, et al. Twenty-five percent albumin prevents lung injury following shock/resuscitation. Crit Care Med. 2003. 31(9): 2355-63. Martin GS, Moss M, Wheeler AP, Mealer M, Morris JA, Bernard GR. A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury. Crit Care Med. 2005. 33(8): 1681-7. Dubois MJ, Orellana-Jimenez C, Melot C, et al. Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study. Crit Care Med. 2006. 34(10): 2536-40. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999. 341(6): 403-9. Steiner C, Mitzner S. Experiences with MARS liver support therapy in liver failure: analysis of 176 patients of the International MARS Registry. Liver. 2002. 22 Suppl 2: 20-5. Mitzner S, Loock J, Peszynski P, et al. Improvement in central nervous system functions during treatment of liver failure with albumin dialysis MARS--a review of clinical, biochemical, and electrophysiological data. Metab Brain Dis. 2002. 17(4): 463-75. Vincent SH, Grady RW, Shaklai N, Snider JM, Muller-Eberhard U. The influence of heme-binding proteins in heme-catalyzed oxidations. Arch Biochem Biophys. 1988. 265(2): 539-50. Kobayashi N, Nagai H, Yasuda Y, Kanazawa K. The early influence of albumin administration on protein metabolism and wound healing in burned rats. Wound Repair Regen. 2004. 12(1): 109-14. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ. 1998. 317(7153): 235-40. Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med. 2001. 135(3): 149-64. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004. 350(22): 2247-56. Martin G. Conflicting clinical trial data: a lesson from albumin. Crit Care. 2005. 9(6): 649-50. Persson J, Grande PO. Volume expansion of albumin, gelatin, hydroxyethyl starch, saline and erythrocytes after haemorrhage in the rat. Intensive Care Med. 2005. 31(2): 296-301. BEEKEN WL, VOLWILER W, GOLDSWORTHY PD, et al. Studies of I-131-albumin catabolism and distribution in normal young male adults. J Clin Invest. 1962. 41: 1312-33.李维勤, 黎介寿, 全竹富, 尹路, 任建安, 韩建明. 严重感染病人低白蛋白血症的影响因素与临床意义. 肠外与肠内营养. 2000. 7(4): 252.Vincent JL, Dubois MJ, Navickis RJ, Wilkes MM. Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials. Ann Surg. 2003. 237(3): 319-34. Haynes GR, Navickis RJ, Wilkes MM. Albumin administration--what is the evidence of clinical benefit? A systematic review of randomized controlled trials. Eur J Anaesthesiol. 2003. 20(10): 771-93. Vincent JL, Wilkes MM, Navickis RJ. Safety of human albumin--serious adverse events reported worldwide in 1998-2000. Br J Anaesth. 2003. 91(5): 625-30. Guidet B, Mosqueda GJ, Priol G, Aegerter P. The COASST study: cost-effectiveness of albumin in severe sepsis and septic shock. J Crit Care. 2007. 22(3): 197-203. Sedrakyan A, Gondek K, Paltiel D, Elefteriades JA. Volume expansion with albumin decreases mortality after coronary artery bypass graft surgery. Chest. 2003. 123(6): 1853-7.