title: Co-administration of furosemide with albumin for overcoming diuretic resistance in patients with hypoalbuminemia: a meta-analysis.
abstract: OBJECTIVE
  To systematically review clinical studies of co-administration of albumin and loop diuretics in hypoalbuminemic patients as a strategy to overcome diuretic resistance.
  
  
  METHODS
  Systematic search of electronic databases up to October 2012. We included randomized clinical trials of adults with hypoalbuminemia, comparing co-administration of loop diuretics and albumin versus loop diuretics alone. Quantitative data were synthesized with meta-analytic techniques for clinical, surrogate (urinary volume and urinary sodium excretion) and intermediate (pharmacokinetic and hemodynamic parameters) outcomes.
  
  
  RESULTS
  Ten studies were included, of which 8 trials with crossover design were synthesized with meta-analysis. A statistically significant increase in the amount of urine volume (increment of 231 mL [95% confidence interval 135.5-326.5]) and sodium excreted (15.9 mEq [4.9-26.8]) at 8 hours were found in favor of co-administration of albumin and furosemide. These differences were no longer statistically significant at 24 hours. Meta-analyses for intermediate outcomes (ie, furosemide excretion, distribution volume etc.) did not reveal statistically significant differences.
  
  
  CONCLUSIONS
  Synthesis of a heterogeneous body of evidence shows transient effects of modest clinical significance for co-administration of albumin with furosemide in hypoalbuminemic patients. Pragmatic, large-scale randomized studies are needed to delineate the role of this strategy.
authors.affiliation: Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA. Electronic address: Georgios.Kitsios@Lahey.org.
authors.forename: Georgios D
authors.initials: GD
authors.lastname: Kitsios
authors.affiliation: Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA.
authors.forename: Paolo
authors.initials: P
authors.lastname: Mascari
authors.affiliation: Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA.
authors.forename: Riad
authors.initials: R
authors.lastname: Ettunsi
authors.affiliation: Department of Internal Medicine and Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA.
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Gray
mesh_terms: D000328:Adult; D000418:Albumins / Q000008:administration & dosage*; D018592:Cross-Over Studies; D004232:Diuretics / Q000008:administration & dosage* / Q000652:urine; D004351:Drug Resistance; D005665:Furosemide / Q000008:administration & dosage* / Q000652:urine; D006801:Humans; D034141:Hypoalbuminemia / Q000628:therapy* / Q000652:urine; D016032:Randomized Controlled Trials as Topic; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000627:therapeutic use; D014556:Urine
chemical_list: D000418:Albumins; D004232:Diuretics; D049994:Sodium Potassium Chloride Symporter Inhibitors; D005665:Furosemide
keywords: Albumin; Diuretic resistance; Furosemide; Hypoalbuminemia; Meta-analysis