At what serum albumin level should albumin infusion be considered in a patient with hypoalbuminemia?

Albumin Infusion in Hypoalbuminemia

Albumin infusions should not be used routinely for the treatment of hypoalbuminemia but should be reserved for specific clinical indications such as large-volume paracentesis (>5L), spontaneous bacterial peritonitis with renal dysfunction, and severe hypovolemic shock. 1

Indications for Albumin Infusion

Albumin infusion is indicated in the following specific scenarios:

1. Large Volume Paracentesis:

   • Albumin (20% or 25% solution) should be infused after paracentesis of >5L at a dose of 8g albumin/L of ascites removed 2
   • For paracentesis <5L, albumin can be considered at the same dose in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 2

2. Spontaneous Bacterial Peritonitis (SBP):

   • In patients with SBP and increased or rising serum creatinine, infusion of 1.5g albumin/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 2

3. Critical Illness:

   • May be considered as a second-line fluid for resuscitation in septic shock, as adjunctive therapy to crystalloids 1

When NOT to Use Albumin Infusion

• Simple hypoalbuminemia without specific indications does not benefit from albumin infusion 1, 3
• Nutritional hypoalbuminemia should be addressed through nutritional support rather than albumin infusion 1
• Hypoalbuminemia in chronic conditions without acute complications does not warrant albumin infusion 1

Management Algorithm for Hypoalbuminemia

1. Assess severity and cause:

   • Severe hypoalbuminemia: <2.5 g/dL 2
   • Moderate hypoalbuminemia: 2.5-3.0 g/dL
   • Mild hypoalbuminemia: 3.0-3.4 g/dL 4

2. Identify underlying cause:

   • Liver disease
   • Malnutrition
   • Inflammation/infection
   • Nephrotic syndrome
   • Protein-losing enteropathy
   • Burns
   • Peritoneal dialysis 1

3. Treat the underlying cause:

   • For liver disease: Manage ascites with diuretics (spironolactone monotherapy or combination with furosemide) 2
   • For malnutrition: Increase protein intake to 1.2-1.5 g/kg/day 1
   • For inflammation: Treat underlying infection or inflammatory condition 1

4. Monitor response:

   • Track serum albumin levels
   • Monitor body weight and BMI
   • Assess other nutritional parameters (transferrin, prealbumin) 1

Special Considerations

• Prognostic significance: Hypoalbuminemia is associated with increased mortality in various conditions including heart failure (HR=2.05) 4 and surgical patients 3
• Persistence of hypoalbuminemia: Patients admitted with hypoalbuminemia who are discharged with normal albumin levels have better survival rates than those who remain hypoalbuminemic (82.4% vs 42.8%) 5
• Severity impact: Patients with albumin <2 g/dL have higher incidence of complications such as diarrhea during enteral feeding (27% vs 10.5% in those with albumin >2 g/dL) 6

Pitfalls and Caveats

• Albumin infusion alone does not improve survival in patients with hypoalbuminemia when the underlying cause is not addressed 3
• Diuretics should be used with caution in hypoalbuminemic patients as they could induce hypovolemia and promote thrombosis 1
• Treating only the low albumin level without addressing the underlying cause is ineffective 1
• Patients with chronic development of hypoalbuminemia have different management needs than those with acute onset 6

Remember that hypoalbuminemia is often a marker of disease severity rather than a disease itself. Treating the underlying condition is paramount for improving outcomes.