What are the indications for using 25% albumin (human albumin)?

Indications for 25% Albumin

25% albumin is primarily indicated for patients with cirrhosis undergoing large-volume paracentesis (>5L) at a dose of 8g albumin/L of ascites removed, and for patients with spontaneous bacterial peritonitis (1.5g/kg on day 1, 1g/kg on day 3). 1, 2

Primary Indications (Strong Evidence)

Cirrhosis-Related Conditions

• Large-volume paracentesis (>5L)

  • Dose: 8g albumin per liter of ascites removed 1, 2
  • Purpose: Prevents post-paracentesis circulatory dysfunction (PPCD)
  • Evidence: Reduces risk of PPCD by 61%, hyponatremia by 42%, and mortality by 36% 2

• Spontaneous bacterial peritonitis (SBP)

  • Dose: 1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 1, 2
  • Especially important in patients with increased serum creatinine or rising creatinine 1
  • Reduces rates of kidney impairment (OR 0.21) and mortality (OR 0.34) 1

Fluid Replacement in Plasmapheresis

• Replacement fluid during therapeutic plasma exchange procedures 3
• Moderate to high quality evidence with strong recommendation 3

Secondary Indications (Moderate Evidence)

Small-Volume Paracentesis (<5L)

• Consider in patients with:
  • Acute-on-chronic liver failure (ACLF)
  • High risk of post-paracentesis acute kidney injury 1, 2
  • Same dosing: 8g albumin/L of ascites removed

Hepatorenal Syndrome

• Part of management strategy for hepatorenal syndrome 3
• Moderate quality evidence with strong recommendation 3

Tertiary Indications (Limited Evidence)

Intradialytic Hypotension

• May be considered in patients with hypoalbuminemia (<30 g/L) experiencing intradialytic hypotension 1, 4
• 25% albumin appears superior to saline for maintaining blood pressure and improving ultrafiltration 4
• However, cost considerations limit routine use (estimated $20,000 per patient annually) 1

Severe Hyponatremia in Cirrhosis

• Low to moderate quality evidence with weak recommendation 3

Acute Ischemic Stroke

• Limited evidence from the ALIAS trials suggests potential benefit 1
• 2g/kg administered over 2 hours within 5 hours of stroke onset
• However, safety concerns regarding pulmonary edema (13% of subjects) exist 1

Intracranial Pressure Management

• Limited historical evidence for use in patients with mild to moderate brain edema 5
• Dose: 2g/kg over 60 minutes
• Creates oncotic gradient to reduce cerebral edema

Important Considerations

Volume Expansion Properties

• 25% albumin provides significant plasma volume expansion (approximately 11mL/g of retained albumin) 6
• More concentrated solutions (20-25%) are considered hyperoncotic and draw fluid from interstitial spaces into the vascular compartment

Administration Guidelines

• Administer slowly after paracentesis is completed to prevent cardiac overload 2
• Exercise caution in patients with pre-existing cardiomyopathy 2

Contraindications/Cautions

• Not recommended for routine treatment of hypoalbuminemia without specific indications 3, 7
• Not recommended for nutritional purposes 3
• Use with caution in cardiac patients due to risk of volume overload
• Potential negative effects on outcome in traumatic brain injury patients (with hyperoncotic albumin) 7

Cost Considerations

• 25% albumin is significantly more expensive than crystalloids or synthetic colloids
• Restricted use is recommended where alternatives exist 7

Practical Algorithm for 25% Albumin Use

1. First-line use (strongly recommended):

   • Large-volume paracentesis >5L (8g/L of ascites)
   • Spontaneous bacterial peritonitis (1.5g/kg day 1, 1g/kg day 3)
   • Plasmapheresis fluid replacement

2. Second-line use (consider if):

   • Small-volume paracentesis in high-risk patients
   • Hepatorenal syndrome
   • Intradialytic hypotension with hypoalbuminemia not responding to other measures

3. Limited evidence use (use with caution):

   • Acute ischemic stroke (within research protocols)
   • Intracranial pressure management
   • Severe hyponatremia in cirrhosis