What are the indications for intravenous (IV) albumin infusion in a patient with nephrotic syndrome?

Indications for IV Albumin Infusion in Nephrotic Syndrome

IV albumin infusion in nephrotic syndrome is primarily indicated for patients with symptomatic hypovolemia, not for normalizing serum albumin levels. 1

Primary Indications

1. Symptomatic Hypovolemia

• Clinical indicators of hypovolemia requiring albumin infusion include:
  • Prolonged capillary refill time
  • Tachycardia
  • Hypotension
  • Oliguria or acute kidney injury
  • Abdominal discomfort
  • Failure to thrive 1, 2

2. Acute Nephrosis

• In patients who do not respond to cyclophosphamide or steroid therapy
• When steroids aggravate underlying edema
• In this situation, a loop diuretic and 100 mL of 25% albumin repeated daily for 7-10 days may help control edema 3

Dosing and Administration

• For patients with severe disease: daily albumin infusions of 1-4 g/kg 1
• For acute nephrosis: 100 mL of 25% albumin daily for 7-10 days 3
• As disease stabilizes or when CKD progresses, albumin dose may be reduced and infusions made less frequent or stopped 1

Important Considerations

Combination with Diuretics

• Intravenous bolus of furosemide (0.5-2 mg/kg) at the end of each albumin infusion is recommended in the absence of marked hypovolemia or hyponatremia 1
• This combination enhances diuresis and improves fluid control 1
• Caution: diuretics should only be used with intravascular fluid overload (evidenced by good peripheral perfusion and high blood pressure) 1

Vascular Access Concerns

• Central venous lines (CVLs) should be avoided when possible due to high risk of thrombosis 1
• If regular albumin infusions are necessary, a CVL becomes necessary with prophylactic anticoagulation recommended 1
• Preserve vasculature for potential future hemodialysis access 1

Limitations and Cautions

Limited Long-term Efficacy

• In chronic nephrosis, infused albumin is promptly excreted by the kidneys with no relief of chronic edema 3
• Weight loss from albumin and diuretic therapy is often transient unless remission of proteinuria occurs 4

Potential Complications

• Hypertension requiring acute antihypertensive therapy (observed in 46% of treatment courses) 4
• Electrolyte disturbances: hypokalemia (40%), hypernatremia (17%), hyperbicarbonatemia (11%) 4
• Respiratory distress, including potential respiratory failure and congestive heart failure 4
• Possible delay in response to corticosteroid therapy and more frequent relapses after remission 5

Decision Algorithm for Albumin Use

1. Assess volume status:

   • If hypovolemic with clinical symptoms → Consider albumin infusion
   • If euvolemic or hypervolemic → Avoid albumin infusion

2. Evaluate response to conventional therapy:

   • If responsive to steroids/immunosuppressants → No albumin needed
   • If unresponsive to conventional therapy with persistent edema → Consider albumin with diuretics

3. Consider disease chronicity:

   • Acute presentation → Albumin may be beneficial
   • Chronic nephrosis → Albumin likely ineffective and not warranted 3

4. Quality of life assessment:

   • Impact on school attendance or daily activities → May factor into decision for albumin therapy 1

Monitoring During Therapy

• Fluid status assessment
• Electrolytes (especially potassium and sodium)
• Blood pressure
• Kidney function (diuresis and estimated glomerular filtration rate)
• Weight changes 1

Remember that albumin infusion is not meant to normalize serum albumin levels but rather to support intravascular volume and reduce extravascular fluid retention in patients with symptomatic hypovolemia 1. The transient nature of its effect (often returning to baseline within 24 hours) should be considered when planning treatment 6.