When to use albumin (human albumin) infusion in adults?

When to Use Albumin Infusion in Adults

Albumin infusion should NOT be used routinely in most clinical scenarios, with the strongest evidence supporting its use only in patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. 1, 2

Evidence-Based Indications for Albumin Therapy

Strong Indications (Recommended Use)

1. Cirrhosis with Complications:

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

2. Plasmapheresis: As replacement fluid during therapeutic plasma exchange 2, 3

Conditional/Weak Indications (Consider Use)

1. Septic shock: As second-line fluid after crystalloids when patients require large volumes of crystalloids 2
2. Severe burns: To maintain plasma albumin concentration around 2.5±0.5g/100mL 4
3. Refractory shock: When other fluids have failed 2

Contraindicated Uses (Not Recommended)

1. Critically ill adults: For routine volume replacement 1, 2
2. Hypoalbuminemia alone: Without specific clinical indications 2, 5
3. Nutritional supplementation: Not justified as a protein source 4
4. Uncomplicated ascites in cirrhosis 2
5. Chronic nephrosis: Albumin is promptly excreted with no benefit 4
6. Chronic conditions: Including chronic cirrhosis, malabsorption, protein-losing enteropathies, pancreatic insufficiency, and undernutrition 4

Administration Guidelines

• Route: Always administer by intravenous infusion only 4
• Rate: Should not exceed 2mL per minute to avoid circulatory overload and pulmonary edema 4
• Monitoring: Patients should be carefully monitored for signs of:
  • Circulatory overload
  • Hypotension
  • Allergic reactions
  • Hemodilution requiring RBC transfusion
  • Anaphylaxis 1, 4

Important Considerations

• Cost: Albumin is expensive (approximately $130 per 25g in the US), making cost-effectiveness an important consideration 2
• Manufacturing: Requires large volumes of plasma 1
• Fluid status: In dehydrated patients, albumin must be given with or followed by additional fluids due to its hyperoncotic properties 4
• Hemorrhage: In patients with hemorrhage, albumin should be supplemented with whole blood transfusion to prevent hemodilution anemia 4

Ongoing Research

Several large randomized clinical trials are currently investigating albumin use in various conditions, which may provide additional clarity in the future:

• Albumin in septic shock
• Albumin in high-risk cardiac surgery
• Long-term albumin administration in decompensated cirrhosis
• Albumin in acute kidney injury 1

The evidence clearly shows that albumin has very limited evidence-based indications, with the strongest support for its use in specific complications of cirrhosis. Implementation of evidence-based guidelines can reduce inappropriate use and costs of intravenous albumin.