When is albumin (human albumin) administered to a patient?

Albumin Administration: Evidence-Based Indications

Albumin should primarily be administered to patients with cirrhosis undergoing large-volume paracentesis (>5L) or with spontaneous bacterial peritonitis, as these are the most evidence-supported indications with clear mortality benefits. 1, 2

Primary Indications for Albumin Administration

Liver Disease-Related Indications

1. Large-Volume Paracentesis (>5L)

   • Dosage: 6-8g albumin per liter of ascitic fluid removed 1, 2
   • Purpose: Prevents post-paracentesis circulatory dysfunction and improves survival 1

2. Spontaneous Bacterial Peritonitis

   • Dosage: 1.5g/kg on day 1, followed by 1g/kg on day 3 1, 2
   • Purpose: Reduces risk of renal impairment and mortality 1

3. Hepatorenal Syndrome

   • Used in combination with vasoconstrictors (e.g., terlipressin) 2
   • Note: Evidence is less robust than for other liver indications 1

Emergency/Critical Care Indications

1. Hypovolemic Shock (Second-Line)

   • Only after crystalloids have been used 3
   • Particularly in cases of delayed treatment with long-standing shock 3

2. Severe Sepsis/Septic Shock

   • As second-line fluid after crystalloids 2
   • Not as first-line volume replacement 2

Specialized Clinical Situations

1. Plasmapheresis

   • Fluid replacement during therapeutic plasma exchange 4

2. Burns

   • May be used beyond 24 hours post-burn to maintain plasma colloid osmotic pressure 3
   • Not indicated in first 24 hours (crystalloids preferred) 3

3. Cardiopulmonary Bypass

   • Used in pump priming to achieve plasma albumin concentration of 2.5 g/100 mL 3

4. Neonatal Hemolytic Disease

   • 1g/kg body weight given about 1 hour prior to exchange transfusion 3
   • Binds free bilirubin, reducing risk of kernicterus 3

Situations Where Albumin is NOT Recommended

1. Hypoalbuminemia without other indications 1, 2, 4

   • Simply correcting low albumin levels is not beneficial

2. Nutritional supplementation 3, 4

   • Not effective as protein nutrition source

3. Routine use in critical care 1, 2

   • No mortality benefit over crystalloids in most ICU patients

4. Chronic nephrosis 3

   • Albumin is promptly excreted with no benefit

5. Chronic cirrhosis without specific complications 1, 3

   • Not beneficial for general management

Important Considerations and Cautions

• Cost implications: Albumin is expensive (~$130/25g) and requires large volumes of plasma for manufacturing 2

• Monitor for complications:

  • Circulatory overload
  • Allergic reactions
  • Transfusion reactions
  • Coagulation derangements 5

• In dehydration: Must be given with or followed by additional fluids to prevent further dehydration 3

• In hemorrhage: Should be supplemented with whole blood transfusion to prevent hemodilution anemia 3

Ongoing Research

Several large randomized clinical trials are currently investigating albumin use in:

• Community-acquired pneumonia with hypoalbuminemia
• Septic shock
• High-risk cardiac surgery
• Acute kidney injury requiring replacement therapy
• Long-term administration in decompensated cirrhosis 1

The evidence clearly demonstrates that albumin has specific, limited indications where it provides clinical benefit but should not be used routinely for volume replacement or correction of hypoalbuminemia alone 1, 2.