What are the indications for human albumin (Albumin)?

From the Guidelines

Albumin is indicated for several clinical conditions where there is a need to restore or maintain plasma volume and oncotic pressure, including hypovolemic shock, burns, hypoalbuminemia, and certain specific conditions like hepatorenal syndrome, spontaneous bacterial peritonitis, and large volume paracentesis. The use of albumin in these conditions is supported by recent guidelines from the International Collaboration for Transfusion Medicine Guidelines 1. For hypovolemic shock, albumin (5% or 25% solution) can be administered intravenously at doses of 0.5-1 g/kg body weight 1. In patients with burns covering more than 30% of body surface area, albumin may be given after the first 24 hours to maintain serum albumin levels above 2.5 g/dL 1. For hypoalbuminemia, albumin is typically reserved for severe cases (serum albumin <2 g/dL) with clinical symptoms like edema or hypotension 1. In hepatorenal syndrome, albumin is administered at 1 g/kg on day 1 and 20-40 g daily thereafter, often in combination with vasoconstrictors 1. For spontaneous bacterial peritonitis, 1.5 g/kg on diagnosis followed by 1 g/kg on day 3 can reduce renal impairment and mortality 1. During large volume paracentesis (>5 liters), albumin at 6-8 g per liter of ascitic fluid removed helps prevent circulatory dysfunction 1. Some key points to consider when using albumin include:

• The use of albumin should be individualized based on the patient's specific condition and needs 1.
• The optimal dose and duration of albumin administration are not well established and may vary depending on the condition being treated 1.
• Albumin should be used judiciously due to its cost and potential risks, including fluid overload, pulmonary edema, and allergic reactions 1.
• The use of albumin in patients with cirrhosis and ascites is recommended for large-volume paracentesis and spontaneous bacterial peritonitis, but its use in other settings is not well established 1. Overall, the use of albumin should be guided by the patient's specific needs and the potential benefits and risks of treatment, as outlined in recent guidelines and studies 1.

From the FDA Drug Label

INDICATIONS AND USAGE Emergency Treatment of Hypovolemic Shock Plasbumin-25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. Burn Therapy Hypoproteinemia With or Without Edema Adult Respiratory Distress Syndrome (ARDS) Cardiopulmonary Bypass Acute Liver Failure Neonatal Hemolytic Disease Sequestration of Protein Rich Fluids Erythrocyte Resuspension Acute Nephrosis Renal Dialysis

The indications for albumin are:

• Emergency treatment of hypovolemic shock
• Burn therapy
• Hypoproteinemia with or without edema
• Adult Respiratory Distress Syndrome (ARDS)
• Cardiopulmonary bypass
• Acute liver failure
• Neonatal hemolytic disease
• Sequestration of protein rich fluids
• Erythrocyte resuspension
• Acute nephrosis
• Renal dialysis 2, 2

From the Research

Indications for Albumin Administration

The following are evidence-based indications for albumin administration:

• Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, with a moderate to high quality of evidence and a strong recommendation 3
• Management of cirrhosis complications, such as fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments 3, 4, 5
• Septic shock, with albumin used as a second-line and adjunctive to crystalloids for fluid resuscitation, having a low to moderate quality of evidence and a weak recommendation 3, 6, 7
• Hypovolemic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia, with a low to moderate quality of evidence and a weak recommendation 3

Clinical Scenarios for Albumin Use

Albumin supplementation is accepted in the following clinical scenarios:

• Patients with cirrhosis and spontaneous bacterial peritonitis 4, 5
• Patients with cirrhosis undergoing large volume paracentesis 4, 5
• Treatment of type 1 hepatorenal syndrome 4, 5
• Fluid resuscitation of patients with sepsis 4, 5
• Therapeutic plasmapheresis with exchange of large volumes of plasma 4, 5
• Burns, nephrotic syndrome, hemorrhagic shock, and prevention of hepatorenal syndrome, although it does not represent a first-choice treatment nor is its use supported by widely accepted guidelines 5