What is the treatment for severe hypoalbuminemia using human albumin?

Treatment of Severe Hypoalbuminemia Using Human Albumin

Intravenous albumin is not recommended for the routine treatment of hypoalbuminemia alone, as there is insufficient evidence that this practice improves clinical outcomes in most patients. 1, 2

Evidence-Based Indications for Albumin Use

Recommended Uses (Strong Evidence)

• Liver Disease Complications:

  • Large-volume paracentesis (>5L): 6-8g per liter of ascitic fluid removed 2
  • Spontaneous bacterial peritonitis: 1.5g/kg on day 1, followed by 1g/kg on day 3 2
  • Hepatorenal syndrome: In conjunction with vasoactive drugs (terlipressin, norepinephrine, or octreotide/midodrine) 2
  • Acute kidney injury in cirrhosis: 1g/kg daily for 2 consecutive days (maximum 100g/day) 2

• Other Evidence-Based Uses:

  • Fluid replacement in plasmapheresis 3

Conditional/Weak Recommendations

• Second-line fluid for resuscitation in septic shock (after crystalloids) 2, 3
• Severe burns (limited evidence of benefit) 3, 4
• Intradialytic hypotension 3
• Severe and refractory edema with hypoalbuminemia not responding to other treatments 3

Contraindications and Cautions

• Not Recommended For:

  • Routine volume replacement in critically ill adults 1, 2
  • Nutritional supplementation 3
  • Uncomplicated ascites in cirrhosis 2
  • Correction of hypoalbuminemia without specific clinical indications 1, 2, 5

• Potential Adverse Effects:

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

Administration Guidelines

• Administer by intravenous infusion only
• Do not exceed 2 mL per minute to avoid circulatory complications and pulmonary edema 2
• Monitor patients carefully to prevent circulatory overload 2

Clinical Decision-Making Algorithm

1. Identify the underlying cause of hypoalbuminemia (inflammation, liver disease, malnutrition, protein loss)
2. Determine if patient has a specific indication for albumin therapy:
   • Cirrhosis with complications (SBP, HRS, large-volume paracentesis)
   • Plasmapheresis
   • Refractory shock (as second-line after crystalloids)
3. If no specific indication exists:
   • Treat the underlying cause of hypoalbuminemia
   • Consider nutritional support if appropriate
   • Avoid albumin administration solely to correct low serum albumin levels
4. If albumin is indicated:
   • Use appropriate dosing for the specific indication
   • Monitor for fluid overload and other adverse effects
   • Reassess need for continued therapy

Important Considerations

• The C-reactive protein/albumin ratio may be a better predictor of mortality than albumin levels alone in critically ill patients 4
• While hypoalbuminemia is associated with poor outcomes, this association may not be causal, and albumin replacement has not consistently been shown to improve outcomes 6
• Albumin is expensive (approximately $130/25g in US), making cost-effectiveness an important consideration 1, 2
• Several large randomized clinical trials are currently investigating albumin use in various conditions, which may provide additional clarity in the future 1, 2