From the Guidelines
Hypoalbuminemia is caused by several distinct mechanisms including decreased production, increased loss, or redistribution of albumin in the body, with the most recent and highest quality study suggesting that inflammation may reduce serum albumin concentrations independently of malnutrition 1.
Causes of Hypoalbuminemia
- Decreased production: Liver disease, such as cirrhosis, hepatitis, and alcoholic liver disease, significantly reduces albumin production, as the liver is responsible for albumin synthesis 1.
- Increased loss:
- Kidney diseases, such as nephrotic syndrome, where damaged glomeruli allow albumin to leak into urine 1.
- Protein-losing enteropathies, such as inflammatory bowel disease, celiac disease, and intestinal lymphangiectasia, cause albumin loss through the gastrointestinal tract 1.
- Burns and other skin conditions can lead to albumin loss through damaged skin surfaces.
- Redistribution of albumin:
- Systemic inflammation from infections, cancer, or autoimmune diseases increases vascular permeability, causing albumin to leak into tissues 1.
- Critical illness and major surgery trigger capillary leak syndrome, redistributing albumin from the bloodstream to interstitial spaces 1.
- Pregnancy and hemodilution from excessive IV fluids can also decrease albumin concentration through dilutional effects.
Treatment and Management
Treatment should target the underlying cause while maintaining adequate nutrition and protein intake, with the aim of downgrading inflammation, enabling withdrawal of steroids, and improving malnutrition 1.
- Nutritional support should be initiated in the presence of malnutrition, in those at nutritional risk at the time of surgery, and in patients who are either unable to eat within 5 days postoperatively or cannot achieve an oral intake of > 50% of the recommended intake within 7 days postoperatively 1.
- Delaying surgery by up to 8 weeks to address modifiable risk factors can reduce postoperative complications and morbidity and may also reduce the postoperative length of stay or the need for a diverting stoma 1.
From the Research
Causes of Hypoalbuminemia
- Cirrhosis 2
- Malnutrition 2, 3, 4, 5
- Nephrotic syndrome 2, 3, 4
- Sepsis 2
- Heart failure 3, 6
- Inflammation 3, 4, 5
- Liver dysfunction 3, 4
- Hemodilution 3
- Protein-losing enteropathy 3
- Increased transcapillary escape rate 3
- Burns 2
- Hemorrhagic shock 2
- Cachexia 3
- Crystalloid overload 4
- Serous losses 4
Disease Associations
- Hypoalbuminemia is associated with several diseases, including cirrhosis, malnutrition, nephrotic syndrome, sepsis, and heart failure 2, 3, 6
- It is also a marker of malnutrition-inflammatory syndrome 6
- Inflammation increases capillary permeability and escape of serum albumin, leading to hypoalbuminemia 5
Clinical Significance
- Hypoalbuminemia has a strong predictive value on mortality and morbidity 2
- It is an independent predictor of incident heart failure in end-stage renal disease and elderly patients 3
- Hypoalbuminemia provides prognostic information incremental to the usual clinical and biochemical variables in patients with heart failure 3
- Patients with hypoalbuminemia have higher in-hospital mortality and longer length of stay compared to those without hypoalbuminemia 6