How to manage low protein and hypoalbuminemia?

From the Guidelines

Managing low protein and hypoalbuminemia requires a comprehensive approach focused on dietary modifications and treating underlying causes, with the goal of increasing protein intake to 1.2-1.5 g/kg body weight daily. This approach is supported by the clinical practice guidelines for nutrition in chronic renal failure, which suggest that protein intakes of less than 0.75 g/kg/d are inadequate for most MHD patients, and that ingestion of 1.1 g of protein/kg/d (with at least 50% of the protein of high biological value) may maintain good protein nutrition in some MHD patients, but is not sufficient to maintain good nutrition in the great majority of clinically stable patients ingesting 25 or 35 kcal/kg/d 1.

Key Recommendations

• Increase protein intake to 1.2-1.5 g/kg body weight daily through protein-rich foods like lean meats, eggs, dairy, legumes, and nuts.
• For severe cases, consider protein supplements such as whey protein (20-25g per serving) or medical nutritional supplements like Ensure or Boost Plus.
• Patients with difficulty consuming adequate protein orally might require enteral nutrition via nasogastric tube or parenteral nutrition in extreme cases.
• Address underlying conditions causing protein loss, such as liver disease, kidney disease, malabsorption disorders, or protein-losing enteropathy.
• Diuretics like furosemide (20-80mg daily) may be needed to manage edema resulting from hypoalbuminemia.
• In critical situations with severe hypoalbuminemia (<2.0 g/dL) causing hemodynamic instability, albumin infusions (25% solution, 50-100g) might be considered, though their benefit is temporary as the underlying cause must be addressed.

Monitoring and Follow-up

Regular monitoring of serum albumin levels, nutritional status, and clinical symptoms is essential to assess treatment effectiveness, as suggested by the guidelines for peritoneal dialysis adequacy, which recommend monitoring serum albumin concentration on a regular basis and evaluating it in the context of the patient’s overall clinical status, including comorbid diseases, peritoneal transport type, delivered dose of PD, and quality-of-life issues 1.

Underlying Causes

It is also important to address the underlying causes of low protein and hypoalbuminemia, such as catabolic illness, which can reduce albumin synthesis and increase albumin degradation, even when dietary protein intake is not low 1. By addressing both protein intake and underlying causes, it is possible to restore normal protein levels and physiological function, and improve patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Causes of Low Protein and Hypoalbuminemia

• Hypoalbuminemia can be associated with several different diseases, including cirrhosis, malnutrition, nephrotic syndrome, and sepsis 2
• Low protein intake, liver dysfunction, and serous losses can contribute to hypoalbuminemia 3
• In patients with heart failure, hypoalbuminemia can result from malnutrition, inflammation, cachexia, hemodilution, liver dysfunction, protein-losing enteropathy, increased transcapillary escape rate, and nephrotic syndrome 4

Treatment of Low Protein and Hypoalbuminemia

• Treatment should focus on addressing the underlying causes and associated conditions, such as a low plasma volume, rather than hypoalbuminemia itself 3
• In patients with cirrhosis and spontaneous bacterial peritonitis, cirrhosis undergoing large volume paracentesis, type 1 hepatorenal syndrome, sepsis, and therapeutic plasmapheresis, albumin supplementation may be indicated 2
• For patients with heart failure, removing subclinical excess fluid and performing a dietary survey, with renutrition if necessary, may be beneficial 4
• Continuous infusion diuretics can be effective in patients with acute decompensated heart failure with hypoalbuminemia, with no significant decrease in diuretic effectiveness 5

Nutritional Support

• Albumin is essential for maintaining plasma colloidal osmotic pressure, preventing edema, and transporting certain drugs and nutrients 6
• Hypoalbuminemia is considered a hallmark of protein-calorie malnutrition and chronic liver disease, and serum albumin may predict response to nutritional support and tolerance to enteral feeding in critically ill patients 6
• However, correcting hypoalbuminemia alone may not lead to major clinical benefits, and further investigations are needed to support the use of albumin infusion in patients with hypoalbuminemia receiving parenteral or enteral nutritional support 6