How to manage a patient with hypoalbuminemia (low albumin level of 2.4 grams per deciliter)?

From the Guidelines

Management of hypoalbuminemia (albumin level of 2.4 g/dL) should focus on identifying and treating the underlying cause, providing nutritional support, and addressing symptoms and complications, rather than solely relying on albumin infusions. The use of intravenous albumin is a common practice in various clinical scenarios, including complications of cirrhosis, intradialytic hypotension, volume resuscitation, and priming of cardiopulmonary bypass circuit, as noted in a 2024 guideline from the international collaboration for transfusion medicine guidelines 1. However, albumin infusions should be reserved for specific indications such as large-volume paracentesis, hepatorenal syndrome, or severe symptomatic edema unresponsive to diuretics.

Key aspects of management include:

• Determining the etiology of hypoalbuminemia, which may include liver disease, nephrotic syndrome, malnutrition, protein-losing enteropathy, or critical illness
• Providing nutritional support with 1.2-1.5 g/kg/day of protein through oral supplements, enteral nutrition, or parenteral nutrition if necessary
• Using diuretics like furosemide 20-40 mg daily (adjusted based on response) for symptomatic patients with edema
• Implementing salt restriction to 2 g/day and fluid restriction as needed in edematous states
• Regularly monitoring albumin levels, electrolytes, and renal function, with albumin checks every 1-2 weeks until improvement

It's essential to note that hypoalbuminemia itself reflects disease severity rather than being a primary target for treatment, and long-term management should focus on treating the underlying condition 1.

From the FDA Drug Label

Unless the underlying pathology responsible for the hypoproteinemia can be corrected, the intravenous administration of Plasbumin-25 must be considered purely symptomatic or supportive The usual daily dose of albumin for adults is 50 to 75 g and for children 25 g. Patients with severe hypoproteinemia who continue to lose albumin may require larger quantities Since hypoproteinemic patients usually have approximately normal blood volumes, the rate of administration of Plasbumin-25 should not exceed 2 mL per minute, as more rapid injection may precipitate circulatory embarrassment and pulmonary edema.

The patient with hypoalbuminemia (low albumin level of 2.4 grams per deciliter) can be managed with intravenous administration of albumin, such as Plasbumin-25.

• The usual daily dose for adults is 50 to 75 g and for children 25 g.
• The rate of administration should not exceed 2 mL per minute to avoid circulatory embarrassment and pulmonary edema.
• Patients with severe hypoproteinemia who continue to lose albumin may require larger quantities of albumin 2, 2.

From the Research

Managing Hypoalbuminemia

To manage a patient with hypoalbuminemia (low albumin level of 2.4 grams per deciliter), the following points should be considered:

• Hypoalbuminemia is frequently observed in hospitalized patients and can be associated with several different diseases, including cirrhosis, malnutrition, nephrotic syndrome, and sepsis 3.
• The use of albumin should be limited to well-defined clinical scenarios, such as 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 3.
• Albumin administration is most indicated in the management of cirrhosis complications, fluid resuscitation, or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments 4.
• The main evidence-based indication for albumin administration is also liver disease, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis 4.

Treatment Approaches

Some treatment approaches for hypoalbuminemia include:

• Correcting the causes of ongoing inflammation rather than infusion of albumin 5.
• Nutrition support to slow down the loss of muscle mass and function, especially when combined with physical exercise 5.
• Using albumin 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 4.

Considerations

When considering the use of albumin, the following points should be taken into account:

• Albumin infusion has not been shown to diminish fluid requirements, infection rates, and mortality in the intensive care unit 5.
• Receiving human albumin infusions may be associated with the development of acute kidney injury in adult patients with minimal change disease 6.
• The quality of evidence for albumin administration in certain clinical scenarios is low to moderate, and the recommendation to use albumin is weak 4.