Management of Hypoalbuminemia: Causes and Treatment Approaches
Hypoalbuminemia should be managed by identifying and treating the underlying cause rather than focusing on albumin replacement therapy, as it is typically a marker of disease rather than a disease itself. 1
Causes of Hypoalbuminemia
Hypoalbuminemia (serum albumin <35 g/L) can result from several mechanisms:
- Decreased production: Liver disease, malnutrition
- Increased losses: Nephrotic syndrome, protein-losing enteropathy, burns
- Increased catabolism: Inflammation, critical illness
- Dilution: Fluid overload, excessive crystalloid administration
- Redistribution: Inflammation causing capillary leak
Diagnostic Approach
- Measure serum albumin levels (hypoalbuminemia defined as <35 g/L)
- Evaluate for underlying causes:
Treatment Strategy
1. Treat the Underlying Cause
- Liver disease: Management of cirrhosis and its complications
- Nephrotic syndrome: ACE inhibitors or ARBs to reduce proteinuria 1
- Inflammatory conditions: Treat underlying infection or inflammatory process
- Malnutrition: Nutritional support
2. Nutritional Management
- Increase protein intake to 1.2-1.5 g/kg/day 1
- Consider oral nutritional supplements 1
- Implement late evening supplementation to reduce overnight catabolism 1
- Early enteral nutrition (within 24-48 hours) for critically ill patients 1
3. Albumin Infusion
Albumin infusion is not recommended for treating hypoalbuminemia solely for the purpose of increasing serum albumin levels 2. However, it is indicated in specific clinical scenarios:
- Large-volume paracentesis (>5L): 8g albumin/L of ascites removed 1
- Spontaneous bacterial peritonitis: 1.5g albumin/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 1
- Hepatorenal syndrome: Terlipressin plus albumin (20-40g/day) 3
- Severe hyponatremia in cirrhosis (<120 mEq/L): Fluid restriction with albumin infusion 3
- Severe and refractory edema with hypoalbuminemia not responding to other treatments 2
4. Pharmacological Interventions
- Diuretics: Use with caution and only in cases of intravascular fluid overload 1
- Antiproteinuric therapy: ACE inhibitors or ARBs for renal disease with proteinuria 1
- Prophylactic anticoagulation: Consider in patients with nephrotic syndrome due to thrombophilic risk 1
Special Considerations
Cirrhosis
- Terlipressin plus albumin (20-40g/day) is effective for hepatorenal syndrome 3
- Continuous IV infusion of terlipressin (initial dose 2mg/day) may have fewer side effects than IV boluses 3
- Monitor for side effects of terlipressin (diarrhea, abdominal pain, cardiovascular complications) 3
Congenital Nephrotic Syndrome
- Base albumin infusions on clinical indicators of hypovolemia rather than serum albumin levels 3
- Consider furosemide (0.5-2 mg/kg) at the end of albumin infusions in the absence of hypovolemia 3
- Avoid central venous lines when possible due to thrombosis risk 3
Drug Dosing
- Hypoalbuminemia affects drug pharmacokinetics, particularly for highly protein-bound medications 4
- Consider therapeutic drug monitoring for medications with narrow therapeutic indices 4
Monitoring
- Regular monitoring of serum albumin levels throughout treatment 1
- Consecutive measurements provide better prognostic information than single values 1
- Monitor at least every 4 months in dialysis patients 1
- Evaluate albumin levels in context with other parameters (inflammation markers, nutritional status) 1
Prognosis
- Hypoalbuminemia is a strong prognostic indicator for poor outcomes in acute surgical patients 5
- Simple albumin infusion or hyperalimentation alone does not improve survival in acute surgical patients with hypoalbuminemia 5
- Treatment of the underlying disease is more important than correcting the albumin level itself 5, 6
Important Caveats
- Albumin infusion should not be used routinely for nutritional purposes 2
- Preoperative correction of hypoalbuminemia may reduce postoperative complications 1
- Albumin is a relatively expensive therapy and should be used judiciously 7
- Hypoalbuminemia can affect drug binding and may require dose adjustments for highly protein-bound medications 4