Is albumin (human albumin) used to treat hypotension (low blood pressure)?

Albumin for Low Blood Pressure

Albumin is not recommended as a first-line treatment for hypotension (low blood pressure) in most clinical scenarios due to lack of evidence showing superiority over less costly alternatives. 1

General Considerations for Albumin Use in Hypotension

Albumin is a plasma protein that can expand blood volume through its oncotic properties. However, its use for treating hypotension should be limited to specific clinical scenarios:

FDA-Approved Indications for Albumin in Hypotension

The FDA label for albumin indicates its use in:

• Emergency treatment of hypovolemic shock: Plasbumin-25 (25% albumin) is hyperoncotic and expands plasma volume by 3-4 times the volume administered by withdrawing fluid from interstitial spaces 2
• Cirrhosis with ascites removal: When removal of ascitic fluid causes cardiovascular changes that may result in hypovolemic shock 2

Evidence Against Routine Use for Hypotension

The International Collaboration for Transfusion Medicine Guidelines (2024) provides several recommendations against routine albumin use:

1. In critically ill adult patients: Albumin is not suggested for first-line volume replacement (Conditional Recommendation, Moderate Certainty of Evidence) 1

2. In patients undergoing kidney replacement therapy: Albumin is not suggested for prevention or treatment of intradialytic hypotension (Conditional Recommendation, Very Low Certainty of Evidence) 1

3. In critically ill patients with thermal injuries or ARDS: Albumin is not suggested for volume replacement (Conditional Recommendation, Very Low Certainty of Evidence) 1

Specific Clinical Scenarios

Intradialytic Hypotension

Despite theoretical benefits, evidence does not support routine albumin use for dialysis-related hypotension:

• A Cochrane review found no difference between 5% albumin and normal saline in achieving target ultrafiltration or other clinical outcomes 3
• Although a 2021 randomized crossover trial showed some improvement in hypotension with 25% albumin compared to saline in patients with serum albumin <30 g/L, the high cost (estimated at $20,000 per patient annually for maintenance dialysis) makes alternative strategies preferable 1

Cirrhosis and Portal Hypertension

Albumin has a more established role in patients with cirrhosis:

• For large-volume paracentesis (>5L), albumin is suggested to prevent paracentesis-induced circulatory dysfunction 1
• In hepatorenal syndrome, albumin in combination with vasoconstrictors is recommended as first-line treatment 1
• Higher cumulative doses of albumin (400-600g) have been associated with improved survival in hepatorenal syndrome 1

Critical Illness and Sepsis

For critically ill patients with cirrhosis and sepsis-induced hypotension:

• Albumin showed higher rates of shock reversal compared to crystalloids but with potential pulmonary complications 1
• The Fluid Resuscitation in Sepsis-Induced Hypotension Among Patients With Cirrhosis study showed higher 1-week survival with 5% albumin versus normal saline (43.5% vs. 38.3%) 1

Potential Risks of Albumin

• Paradoxical hypotension: Rapid infusion of albumin can actually cause hypotension, particularly in patients taking ACE inhibitors (11% incidence in one study) 4
• Fluid overload: Targeting specific albumin levels may lead to pulmonary edema 1
• Cost: Albumin is significantly more expensive than crystalloids with minimal proven benefit 1, 3

Algorithm for Albumin Use in Hypotension

1. First-line treatment for most hypotension: Use crystalloids (balanced solutions like lactated Ringer's preferred over normal saline) 1

2. Consider albumin only in these specific scenarios:

   • Hypovolemic shock not responding to crystalloids 2
   • Cirrhosis with hypotension following large-volume paracentesis 1, 2
   • Hepatorenal syndrome (in combination with vasoconstrictors) 1
   • Sepsis-induced hypotension in patients with cirrhosis (may consider 5% albumin) 1

3. Administration considerations:

   • For hypovolemic shock: Adapt volume and infusion speed to patient response 2
   • For non-shock hypotension: Do not exceed 2 mL/minute to avoid circulatory embarrassment 2
   • Monitor for paradoxical hypotension, especially in patients on ACE inhibitors 4

Conclusion

While albumin has theoretical benefits for treating hypotension through its oncotic properties, current evidence does not support its routine use as a first-line treatment for most cases of hypotension. Crystalloids remain the preferred initial therapy due to similar efficacy, lower cost, and fewer potential complications.