title: A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury.
abstract: OBJECTIVE
  Hypoproteinemia is a common condition in critically ill patients, associated with the development of acute lung injury and acute respiratory distress syndrome and subsequent worse clinical outcomes. Albumin with furosemide benefits lung physiology in hypoproteinemic patients with acute lung injury/acute respiratory distress syndrome, but the independent pharmacologic effects of these drugs are unknown.
  
  
  METHODS
  Randomized, double-blinded, placebo-controlled multicentered trial.
  
  
  METHODS
  Eleven medical, surgical, and trauma intensive care units including 190 beds within two university hospital systems.
  
  
  METHODS
  Forty mechanically ventilated patients with acute lung injury/acute respiratory distress syndrome, whose serum total protein concentrations were <6.0 g/dL were included. Patients were excluded for hemodynamic instability or significant renal or hepatic failure.
  
  
  METHODS
  Subjects were equally randomly allocated to receive furosemide with albumin or furosemide with placebo for 72 hrs, titrated to fluid loss and normalization of serum total protein concentration.
  
  
  RESULTS
  The primary outcome was change in oxygenation from baseline to day 1, with secondary physiologic and clinical outcomes. There were no differences in baseline characteristics of the subjects in relation to group assignment. Albumin-treated patients had greater increases in oxygenation (mean change in Pao2/Fio2: +43 vs. -24 mm Hg at 24 hrs and +49 vs. -13 mm Hg at day 3), serum total protein (1.5 vs. 0.5 g/dL at day 3), and net fluid loss (-5480 vs. -1490 mL at day 3) throughout the study period (all p < .05). Fluid bolus administration to control patients reduced net negative fluid balance; control patients more frequently developed hypotension and had fewer shock-free days, which translated to differences in organ failure at study end.
  
  
  CONCLUSIONS
  The addition of albumin to furosemide therapy in hypoproteinemic patients with acute lung injury/acute respiratory distress syndrome significantly improves oxygenation, with greater net negative fluid balance and better maintenance of hemodynamic stability. Additional randomized clinical trials are necessary to examine mechanisms and determine the effect on important clinical outcomes, such as the duration of mechanical ventilation.
authors.affiliation: Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Greg S
authors.initials: GS
authors.lastname: Martin
authors.forename: Marc
authors.initials: M
authors.lastname: Moss
authors.forename: Arthur P
authors.initials: AP
authors.lastname: Wheeler
authors.forename: Meredith
authors.initials: M
authors.lastname: Mealer
authors.forename: John A
authors.initials: JA
authors.lastname: Morris
authors.forename: Gordon R
authors.initials: GR
authors.lastname: Bernard
mesh_terms: D003131:Combined Modality Therapy; D004232:Diuretics / Q000627:therapeutic use*; D004311:Double-Blind Method; D005260:Female; D005665:Furosemide / Q000627:therapeutic use*; D006439:Hemodynamics; D006801:Humans; D007019:Hypoproteinemia / Q000209:etiology / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012128:Respiratory Distress Syndrome / Q000150:complications / Q000628:therapy*; D015656:Respiratory Mechanics; D012709:Serum Albumin / Q000627:therapeutic use*; D014882:Water-Electrolyte Balance
chemical_list: D004232:Diuretics; D012709:Serum Albumin; D005665:Furosemide