From the Guidelines
Albumin is primarily indicated for volume expansion in patients with hypovolemia, particularly when crystalloids are insufficient or contraindicated, and is specifically recommended for patients with cirrhosis who have spontaneous bacterial peritonitis, hepatorenal syndrome, or require large-volume paracentesis. The use of albumin in these settings is supported by recent studies, including a 2024 guideline from the International Collaboration for Transfusion Medicine Guidelines 1 and a 2024 study published in Hepatology 1, which highlight the benefits of albumin in preventing renal impairment and reducing mortality in patients with cirrhosis and spontaneous bacterial peritonitis. Some key points to consider when using albumin include:
- The typical dosing ranges from 25g to 100g (as 5% or 25% solutions) depending on the indication and patient response 1
- Albumin works by increasing oncotic pressure within the intravascular space, drawing fluid from interstitial spaces into the circulation 1
- Albumin should be used judiciously due to its high cost and limited evidence for mortality benefit in many conditions 1
- It's not routinely recommended for nutritional support, uncomplicated hypoalbuminemia, or as a first-line fluid for general resuscitation where crystalloids are typically adequate 1 Additionally, a 2021 guideline on the management of ascites in cirrhosis recommends the use of albumin in patients with spontaneous bacterial peritonitis to prevent the development of renal dysfunction and decrease mortality 1. However, the use of albumin in other settings, such as in patients with cirrhosis and extraperitoneal infections, is not supported by current evidence 1. Overall, the decision to use albumin should be made on a case-by-case basis, taking into account the individual patient's needs and the potential benefits and risks of treatment.
From the FDA Drug Label
INDICATIONS AND USAGE 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
The indications for albumin use 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 2
From the Research
Indications for Albumin Use
The indications for albumin use can be summarized as follows:
- Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin 3
- Albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic 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 has a low to moderate quality of evidence and weak recommendation to use 3
- Albumin administration is most indicated in management of cirrhosis complications, such as prevention of circulatory dysfunction after large-volume paracentesis, prevention of hepatorenal syndrome in patients with spontaneous bacterial peritonitis, and management of hepatorenal syndrome in combination with vasoconstrictors 4, 5, 6
- Long-term albumin therapy in patients with cirrhosis and ascites may improve survival, prevent complications, simplify ascites management, and lower hospitalization rates 4
- Albumin supplementation should be limited to well-defined clinical scenarios, including patients with cirrhosis and spontaneous bacterial peritonitis, patients with cirrhosis undergoing large volume paracentesis, the treatment of type 1 hepatorenal syndrome, fluid resuscitation of patients with sepsis, and therapeutic plasmapheresis with exchange of large volumes of plasma 7
Specific Clinical Scenarios
Some specific clinical scenarios where albumin use is indicated or has been studied include:
- Large-volume paracentesis 3, 4, 5, 6
- Spontaneous bacterial peritonitis 3, 4, 5, 7, 6
- Hepatorenal syndrome 3, 4, 5, 7, 6
- Sepsis and septic shock 3, 7
- Severe burns 3
- Ovarian hyperstimulation syndrome 3
- Major surgery 3
- Non-traumatic brain injury 3
- Extracorporeal membrane oxygenation 3
- Acute respiratory distress syndrome 3
- Severe and refractory edema with hypoalbuminemia 3