RETHINKING ALBUMIN PRIMING : A TARGETED STRATEGY FOR RESOURCE-LIMITED ICUs

Intermittent hemodialysis (IHD) remains a key kidney replacement therapy in resource-limited intensive care units (ICUs), where continuous therapy (CKRT) is often unavailable. In unstable patients, IHD is commonly delivered as sustained low-efficiency dialysis (SLED), though sessions in our setting are frequently shortened to about 4 hours due to manpower and resource constraints. While such adaptations improve feasibility, their effect on hemodynamic stability is unclear. To enhance tolerance, albumin priming are sometimes used, but evidence guiding their use is limited. This study aimed to identify factors associated with intradialytic hypotension (IDH) and determine which patients may benefit most from albumin-primed IHD in resource-limited ICU settings.

This was a single-centre, retrospective observational study conducted in the intensive care units of Hospital Kuala Lumpur. Medical records of all patients prescribed IHD between January 1 and March 31, 2025, were reviewed. A total of 88 critically ill patients (68 with acute kidney injury (AKI) and 20 with end-stage kidney disease (ESKD) underwent 167 IHD sessions, of which 166 were analysed. Dialysis treatments were performed using Fresenius 4008S and 5008S machines.Each session was evaluated for therapy completion, IDH occurrence, priming strategies, and their association with SOFA scores. Treatment adequacy was defined pragmatically as completion of the prescribed session and achievement of ≥80% of the intended ultrafiltration goal.

IDH was defined as hemodynamic instability requiring intervention resulting in premature termination of therapy, reduction in ultrafiltration rate to <80% of the target, or escalation of vasopressor support during dialysis. Comparisons were made between AKI and ESKD groups to assess differences in dialysis prescription parameters, priming practices, and IDH incidence. It was assumed that, in all sessions, nephrologists had employed standard IDH prevention strategies including cool dialysate temperature, gradual ultrafiltration profiling, and optimization of vasopressor and volume status, before considering albumin priming as an adjunctive measure.

IDH occurred in approximately one-third of all sessions (53% in AKI vs. 42% in ESKD; p = 0.24). A trend toward higher IDH risk was observed in patients with SOFA scores >11, while hypoalbuminemia alone (<30 g/L) was not a consistent predictor. In the high-risk subgroup (SOFA >11 with hypoalbuminemia), albumin priming using ≥20% solutions showed a potential protective effect against IDH (odds ratio 0.36; 95% CI 0.23–0.57; p = 0.07), although statistical significance was not achieved due to the limited sample size. These findings suggest that patients with greater illness severity and concurrent hypoalbuminemia may derive hemodynamic benefit from albumin priming during IHD when CKRT is not available.

In resource-limited ICUs, selective albumin priming should be considered for patients with high illness severity (SOFA >11) and hypoalbuminemia (<30 g/L) who are at risk of intradialytic hypotension or have previously failed saline-primed sessions. This targeted approach complements conventional IDH prevention strategies, optimizing hemodynamic stability while balancing safety, feasibility, and cost, and prioritizing patients most likely to benefit when continuous KRT is not feasible.

(Similar data were used for poster submission at the Asia Pacific AKI–CRRT Conference, October 2025)