What are the indications for albumin (human albumin) transfusion?

From the Guidelines

Human albumin transfusion is indicated for specific clinical scenarios, including spontaneous bacterial peritonitis, hepatorenal syndrome, and large-volume paracentesis, as well as severe hypoalbuminemia with clinical complications, based on the most recent and highest quality evidence from 2024 1.

Indications for Albumin Transfusion

The main indications for albumin transfusion include:

• Volume expansion in patients with hypovolemic shock, particularly when crystalloids alone are insufficient
• Management of patients with severe burns (typically >30% total body surface area)
• Treatment of spontaneous bacterial peritonitis in cirrhotic patients (typically 1.5 g/kg on day 1, followed by 1 g/kg on day 3) 1
• Large-volume paracentesis (typically 6-8 g per liter of ascitic fluid removed) to prevent circulatory dysfunction
• Hepatorenal syndrome (typically 1 g/kg on day 1, followed by 20-40 g/day) 1
• Severe hypoalbuminemia (<2 g/dL) with clinical complications like edema or respiratory compromise
• Certain cases of nephrotic syndrome with severe edema unresponsive to diuretics

Rationale for Albumin Use

Albumin works by maintaining oncotic pressure in the intravascular space, drawing fluid from interstitial spaces into the circulation, and carrying various substances including drugs, hormones, and bilirubin. However, albumin should not be used routinely for all hypoalbuminemic patients, as nutritional support is often more appropriate for chronic cases, and albumin is relatively expensive with limited availability 1.

Important Considerations

It is essential to note that the use of albumin should be individualized and based on the specific clinical scenario, as the evidence for its use is not universally applicable 1. Additionally, the potential risks and benefits of albumin transfusion should be carefully weighed, considering the patient's underlying condition, the severity of their illness, and the potential for adverse events such as fluid overload and pulmonary edema 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. In such circumstances, the use of an albumin infusion may be required to support the blood volume. Burn Therapy An optimal therapeutic regimen with respect to the administration of colloids, crystalloids, and water following extensive burns has not been established. During the first 24 hours after sustaining thermal injury, large volumes of crystalloids are infused to restore the depleted extracellular fluid volume Beyond 24 hours Plasbumin-25 can be used to maintain plasma colloid osmotic pressure. Hypoproteinemia With or Without Edema During major surgery, patients can lose over half of their circulating albumin with the attendant complications of oncotic deficit. Adult Respiratory Distress Syndrome (ARDS) This is characterized by deficient oxygenation caused by pulmonary interstitial edema complicating shock and postsurgical conditions. When clinical signs are those of hypoproteinemia with a fluid volume overload, Plasbumin-25 together with a diuretic may play a role in therapy Cardiopulmonary Bypass With the relatively small priming volume required with modern pumps, preoperative dilution of the blood using albumin and crystalloid has been shown to be safe and well-tolerated Acute Liver Failure In the uncommon situation of rapid loss of liver function with or without coma, administration of albumin may serve the double purpose of supporting the colloid osmotic pressure of the plasma as well as binding excess plasma bilirubin Neonatal Hemolytic Disease The administration of Plasbumin-25 may be indicated prior to exchange transfusion, in order to bind free bilirubin, thus lessening the risk of kernicterus. Sequestration of Protein Rich Fluids This occurs in such conditions as acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis. The magnitude of loss into the third space may require treatment of reduced volume or oncotic activity with an infusion of albumin

The indications for albumin (human albumin) transfusion are:

• Emergency Treatment of Hypovolemic Shock
• Burn Therapy: to maintain plasma colloid osmotic pressure beyond 24 hours after thermal injury
• Hypoproteinemia With or Without Edema: during major surgery or in sepsis or intensive care patients
• Adult Respiratory Distress Syndrome (ARDS): when clinical signs are those of hypoproteinemia with a fluid volume overload
• Cardiopulmonary Bypass: to support the blood volume during preoperative dilution of the blood
• Acute Liver Failure: to support the colloid osmotic pressure of the plasma and bind excess plasma bilirubin
• Neonatal Hemolytic Disease: prior to exchange transfusion to bind free bilirubin and lessen the risk of kernicterus
• Sequestration of Protein Rich Fluids: in conditions such as acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis 2 2

From the Research

Indications for Albumin Transfusion

The indications for albumin transfusion are varied and have been extensively studied. Some of the main indications include:

• Resuscitation in shock states, especially distributive shocks such as septic shock 3
• Liver disease, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis 3, 4, 5
• Fluid replacement in plasmapheresis 3, 4
• 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 3
• Management of cirrhosis complications, including ascites, hepatic encephalopathy, and hepatorenal syndrome 5, 6, 7
• Prevention and treatment of type 1 hepatorenal syndrome associated with bacterial infections 7
• Treatment of spontaneous bacterial peritonitis 5, 6, 7

Specific Clinical Scenarios

In specific clinical scenarios, albumin transfusion may be indicated, including:

• Patients with cirrhosis undergoing large-volume paracentesis 3, 4, 5
• Patients with cirrhosis and spontaneous bacterial peritonitis 3, 4, 5, 6, 7
• Patients with type 1 hepatorenal syndrome 3, 4, 7
• Patients with severe burns, toxic epidermal necrolysis, and intradialytic hypotension 3
• Patients with ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia 3

Evidence-Based Recommendations

Evidence-based recommendations for albumin transfusion have been proposed by international medical societies, including the use of albumin in patients with cirrhosis undergoing large-volume paracentesis, patients with spontaneous bacterial peritonitis, and patients with type 1 hepatorenal syndrome 5, 6, 7. However, the indications for albumin transfusion in different clinical scenarios and the optimal infusion strategy are still being explored and debated 3, 6.