What is the recommended use of albumin (intravenous) IV in clinical practice?

Recommended Uses of Intravenous Albumin in Clinical Practice

Intravenous albumin should only be administered for specific evidence-based indications, with the strongest support for use in patients with cirrhosis undergoing large-volume paracentesis (>5L) or with spontaneous bacterial peritonitis, as these indications have demonstrated mortality benefits.

Established Indications with Strong Evidence

Liver Disease Complications

• Large-Volume Paracentesis (>5L)

  • Recommended dose: 6-8g per liter of ascitic fluid removed 1, 2
  • Prevents paracentesis-induced circulatory dysfunction 1
  • Reduces risk of renal impairment and mortality

• Spontaneous Bacterial Peritonitis (SBP)

  • Recommended dose: 1.5g/kg on day 1, followed by 1g/kg on day 3 1, 2
  • Significantly reduces rate of AKI (10% vs 33%) and death (10% vs 29%) compared to antibiotics alone 1
  • Patients with serum bilirubin >4 mg/dL and baseline AKI are at highest risk and most likely to benefit 1

• Hepatorenal Syndrome (HRS-AKI)

  • IV albumin is the volume expander of choice in hospitalized patients with cirrhosis and ascites presenting with AKI 1
  • Recommended dose: 1 g/kg of body weight daily for 2 consecutive days (maximum 100 g/day) 1
  • Should be used in conjunction with vasoactive drugs (terlipressin, norepinephrine, or octreotide/midodrine) 1

Emergency Treatment of Hypovolemic Shock

• May be used when patients require large volumes of crystalloids 3
• Total dose should not exceed 2g per kg body weight in the absence of active bleeding 3
• Should be administered with caution to avoid circulatory overload 3

Conditional/Limited Indications

Burns

• May be used beyond 24 hours after thermal injury to maintain plasma colloid osmotic pressure 3
• Aim to maintain plasma albumin concentration around 2.5 ± 0.5 g per 100 mL 3
• Not recommended during the first 24 hours when crystalloids are preferred 3

Plasmapheresis

• Used as replacement fluid in therapeutic plasma exchange 4
• Has moderate to high quality evidence supporting its use 4

Not Recommended Uses

1. Hypoalbuminemia without other indications 2, 5

   • Correcting low albumin levels alone does not improve outcomes
   • Not recommended for nutritional purposes 4

2. Routine volume replacement in critically ill adults 1, 2

   • Crystalloids are equally effective and significantly less expensive
   • No mortality benefit over crystalloids in most ICU patients 2

3. Chronic cirrhosis without specific complications 1, 2

   • Albumin should not be used in patients with cirrhosis and uncomplicated ascites 1

4. Kidney replacement therapy 1

   • Not recommended for prevention or treatment of intradialytic hypotension 1
   • Minimal evidence supporting routine use despite frequent practice 6

5. Infections other than SBP 1

   • Does not reduce risk of AKI or mortality
   • Associated with increased risk of pulmonary edema 1

Administration Considerations

• Always administer by intravenous infusion 3
• Can be given undiluted or diluted in 0.9% Sodium Chloride or 5% Dextrose in Water 3
• In hypoproteinemia, administration rate should not exceed 2 mL per minute to avoid circulatory embarrassment and pulmonary edema 3
• Monitor patients carefully to prevent circulatory overload 3
• In hemorrhage, supplement albumin with whole blood transfusion to treat relative anemia associated with hemodilution 3

Potential Adverse Effects

• Fluid overload and pulmonary edema
• Hypotension
• Hemodilution requiring RBC transfusion
• Anaphylaxis
• Peripheral gangrene from dilution of natural anticoagulants 2

Cost Considerations

• Albumin is expensive (approximately $130/25g in US) and requires large volumes of plasma for manufacturing 2
• Implementation of evidence-based guidelines can reduce inappropriate use and costs 4
• Crystalloids are significantly less expensive and equally effective for many indications 2

The evidence clearly demonstrates that albumin has specific, limited indications where it provides clinical benefit, but it should not be used routinely for volume replacement or correction of hypoalbuminemia alone. Following these evidence-based recommendations will optimize patient outcomes while ensuring appropriate resource utilization.