What is the role of albumin and diuresis in managing anasarca?

Management of Anasarca with Albumin and Diuretics

Diuretics combined with albumin infusions are the cornerstone of anasarca management, with spironolactone as first-line therapy (100-400 mg/day) followed by the addition of furosemide (40-160 mg/day) for refractory cases. 1

Assessment of Volume Status

Before initiating therapy, careful assessment of intravascular volume status is critical:

• Signs of intravascular depletion: Prolonged capillary refill time, tachycardia, hypotension, oliguria
• Signs of intravascular overload: Good peripheral perfusion, elevated blood pressure

Diuretic Therapy Algorithm

First-Line Approach

1. Spironolactone monotherapy:
   • Start at 100 mg/day
   • Gradually increase to maximum 400 mg/day if needed
   • Allow 3-5 days for onset of natriuretic effect 1
   • Monitor for side effects: gynecomastia, menstrual irregularity, hyperkalemia

Second-Line Approach (if spironolactone alone is insufficient)

1. Add furosemide:
   • Initial dose: 40 mg/day
   • Increase every 2-3 days as needed
   • Maximum dose: 160 mg/day 1
   • Administer IV (1-2 mg/kg) when rapid diuresis is needed 2

Monitoring During Diuretic Therapy

• Daily weight
• Serum electrolytes (especially sodium and potassium)
• Renal function (creatinine)
• Blood pressure
• Clinical assessment of edema

Albumin Infusions

Indications for Albumin

• Symptomatic hypovolemia despite diuretic therapy
• Diuretic resistance
• Severe hyponatremia (serum sodium ≤125 mmol/L) 1

Administration Protocol

• Dosage: 20-40 g per infusion 1
• Timing: Consider administering furosemide (0.5-2 mg/kg IV) at the end of albumin infusion to enhance diuresis 1
• Frequency: Based on clinical response and severity of anasarca

Special Considerations

Hyponatremia Management

• Serum sodium >126 mmol/L: Continue diuretics, no water restriction
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics and give volume expansion
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion with colloid 1

Refractory Ascites

For patients with refractory ascites (part of anasarca):

1. Large volume paracentesis (LVP) with albumin replacement (8 g/L of ascites removed) 1
2. Resume diuretics 1-2 days after paracentesis 1

Pitfalls and Caveats

1. Avoid over-diuresis: Can lead to intravascular volume depletion, renal impairment, hepatic encephalopathy, and hyponatremia 1

2. Monitor for diuretic complications:

   • Electrolyte imbalances (hypokalemia, hyponatremia)
   • Renal dysfunction
   • Hepatic encephalopathy
   • Muscle cramps

3. Contraindications to aggressive diuresis:

   • Hepatic encephalopathy
   • Severe hyponatremia (serum sodium <120 mmol/L)
   • Rising serum creatinine
   • Hypotension

4. Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers in patients with cirrhotic ascites as they can worsen renal function 1

5. Central venous line considerations: When regular albumin infusions are needed, weigh the benefits against risks of thrombosis and infection 1

Special Populations

Pediatric Patients

• Furosemide: 0.5-2 mg/kg per dose up to six times daily (maximum 10 mg/kg/day) 3
• High doses (>6 mg/kg/day) should not be given for longer than 1 week 3

By following this structured approach to managing anasarca with albumin and diuretics, clinicians can effectively reduce fluid overload while minimizing complications and improving patient outcomes.