Question 25 from the first paper of 2010 and the near-identical Question 5 from the second paper of 2004 both asked the candidate to "critically evaluate the use of albumin" in critically ill patients. Judging by the college answers, these questions were not after an in-depth dissection of outcomes literature. Rather, they may be better worded as "how many legitimate uses of albumin can you think of?"
As noted in the discussion of Question 25, the best single reference for this sort of question is a review article by Luciano Gattinoni and Pietro Caironi, "The clinical use of albumin: the point of view of a specialist in intensive care" (2009). Unless otherwise referenced, this article is the main source of the information summarised below. Another good resource is the 2014 article by J.L Vincent for Critical Care. Additional local sources of information include the following articles:
As with any "critically evaluate" style question, a discussion of albumin should begin with the exploration of those properties which render it desirable as a pharmacological agent. What makes it so attractive?
This enjoys a ...robust discussion... in the chapter which deals directly with the colloid vs crystalloid debate. In short, if one looks for mortality benefits, there will be none. Highly criticised posthoc analysis of subgroups has revealed advantages (and disadvantages) in specific populations, but meta-analysis has not revealed any sort of miraculous resuscitative properties to albumin. Even when compared to the (hideously toxic) normal saline, 4% albumin was found to be equivalent in terms of mortality (SAFE study). Much has been made of the findings of the SAFE study. The most recent ALBIOS study has supported the notion that albumin and saline are equivalent as resuscitation fluids. Furthermore, the authors found that the patients enrolled in early stages of sepsis did not demonstrate an early benefit, and that patients treated with albumin for longer tended to benefit more. This suggests that the benefit of albumin is derived not from a purely oncotic effect, but rather due to its ancillary functions as a nitric oxide modulator, antioxidant and anti-immunosuppressive. This is supported by the last salvo fired by Marik, who suggested that the contribution of albumin infusion to maintaining the integrity of the vascular endothelial glycocalyx is enough to support its role as "a reasonable intervention" in sepsis.
In brief, decades of debate can be glibly summarised as follows:
The recent AISF statement paper (2016) is an excellent resource for this material: it is in effect a literature review of all the available evidence for the use of albumin in liver disease patients.
McEvoy, Rinaldo Bellomo, et al. "The SAFE Study Investigators Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis." Intensive Care Med 37 (2011): 86-96.
Finfer, Simon, et al. "A comparison of albumin and saline for fluid resuscitation in the intensive care unit." N Engl j Med 350.22 (2004): 2247-2256.
Caironi, Pietro, et al. "Albumin replacement in patients with severe sepsis or septic shock." New England Journal of Medicine 370.15 (2014): 1412-1421.
Marik, Paul E. "Early Management of Severe Sepsis: Concepts and Controversies." CHEST Journal 145.6 (2014): 1407-1418.
Patel, Amit, et al. "Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality." BMJ 349 (2014): g4561.
Myburgh, John, et al. "Saline or albumin for fluid resuscitation in patients with traumatic brain injury." N Engl J Med 357.9 (2007): 874-884.
Bernardi, Mauro, Caterina Maggioli, and Giacomo Zaccherini. "Human albumin in the management of complications of liver cirrhosis." Crit Care 16.2 (2012): 211.
Gluud, Lise L., et al. "Systematic review of randomized trials on vasoconstrictor drugs for hepatorenal syndrome." Hepatology 51.2 (2010): 576-584.
Sort, Pau, et al. "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis." New England Journal of Medicine 341.6 (1999): 403-409.
Karvellas, Constantine J., et al. "Bench-to-bedside review: current evidence for extracorporeal albumin dialysis systems in liver failure." Crit Care 11.3 (2007): 215.
Martin, Greg S., et al. "A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury." Critical care medicine 33.8 (2005): 1681-1687.
Caironi, Pietro, and Luciano Gattinoni. "The clinical use of albumin: the point of view of a specialist in intensive care." Blood Transfusion 7.4 (2009): 259.
Dubois, Marc-Jacques, et al. "Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study*." Critical care medicine 34.10 (2006): 2536-2540.
Vincent, Jean-Louis, et al. "Albumin administration in the acutely ill: what is new and where next." Crit Care 18.4 (2014): 231.
Vincent, Jean-Louis, et al. "Hypoalbuminemia in acute illness: Is there a rationale for intervention." Ann Surg 237.3 (2003): 319-334.
Thévenot, Thierry, et al. "Effect of albumin in cirrhotic patients with infection other than spontaneous bacterial peritonitis. A randomized trial." Journal of hepatology 62.4 (2015): 822-830.
Salerno, Francesco, Roberta J. Navickis, and Mahlon M. Wilkes. "Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials." Clinical Gastroenterology and Hepatology 11.2 (2013): 123-130.
Kwok, Chun Shing, et al. "Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: a systematic review and meta-analysis." BioMed research international 2013 (2013).
Johnson, Kara B., et al. "Reduced Albumin Dosing During Large-Volume Paracentesis Is Not Associated with Adverse Clinical Outcomes." Digestive diseases and sciences 60.7 (2015): 2190-2195.
Italian Association for the Study of the Liver (AISF. "AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis." Digestive and Liver Disease 48.1 (2016): 4-15.
Jalan, R., et al. "[232] ALBUMIN INFUSION FOR SEVERE HYPONATREMIA IN PATIENTS WITH REFRACTORY ASCITES: A RANDOMIZED CLINICAL TRIAL." Journal of Hepatology 46 (2007): S95.
Valerio, Christopher, et al. "Human albumin solution for patients with cirrhosis and acute on chronic liver failure: Beyond simple volume expansion." World Journal of Hepatology 8.7 (2016): 345.
Shen, Yi, et al. "Survival Benefits With Artificial Liver Support System for Acute-on-Chronic Liver Failure: A Time Series-Based Meta-Analysis." Medicine 95.3 (2016): e2506.
Sponholz, Christoph, et al. "Molecular adsorbent recirculating system and single-pass albumin dialysis in liver failure–a prospective, randomised crossover study." Critical Care 20.1 (2015): 1-13.
Cooper, D. James, et al. "Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality?." Journal of neurotrauma 30.7 (2013): 512-518.
Gattinoni, Luciano, Massimo Cressoni, and Luca Brazzi. "Fluids in ARDS: from onset through recovery." Current opinion in critical care 20.4 (2014): 373-377.
Martin, Greg S., et al. "Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury*." Critical care medicine 30.10 (2002): 2175-2182.
Martin, Greg S., et al. "A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury." Critical care medicine 33.8 (2005): 1681-1687.
Oczkowski, Simon JW, et al. "Furosemide and albumin for diuresis of edema (FADE): a study protocol for a randomized controlled trial." Trials 15.1 (2014): 222.
Mohammadi, Ali Akbar, et al. "Parenteral Albumin Therapy in Burn Patients: A Randomized Controlled Trial." Iranian Journal of Medical Sciences 35.2 (2015): 95-100.
Becker, Bernhard F., et al. "Therapeutic strategies targeting the endothelial glycocalyx: acute deficits, but great potential." Cardiovascular research 87.2 (2010): 300-310.
Habashi, Nader M., Penny L. Andrews, and Thomas M. Scalea. "Therapeutic aspects of fat embolism syndrome." Injury 37.4 (2006): S68-S73.