When to Check Serum Albumin Levels
Serum albumin should be checked when patients present with edema, suspected liver disease, kidney disease, malnutrition, or specific conditions like nephrotic syndrome and spontaneous bacterial peritonitis, as these conditions are associated with significant morbidity and mortality related to hypoalbuminemia. 1
Clinical Scenarios Requiring Albumin Testing
Kidney-Related Conditions
- Suspected nephrotic syndrome (edema, foamy urine)
- Proteinuria detection and monitoring
- Chronic kidney disease evaluation and staging
- Dialysis patients with poor nutritional status
- Acute kidney injury with volume overload
Liver-Related Conditions
- Cirrhosis with ascites
- Spontaneous bacterial peritonitis (SBP)
- Suspected hepatorenal syndrome
- Before large volume paracentesis
- Patients with Child-Pugh score assessment 1
Gastrointestinal Conditions
- Malabsorption syndromes
- Protein-losing enteropathies
- Inflammatory bowel disease with suspected malnutrition
- Chronic diarrhea with weight loss
Cardiac Conditions
- Decompensated heart failure with edema
- Suspected protein-losing enteropathy due to right heart failure 2
Critical Illness
- Sepsis and septic shock
- Burns
- Major trauma
- Critically ill patients with edema
- Patients requiring plasmapheresis 1, 3
Specific Symptoms That Warrant Albumin Testing
Edema
- Peripheral edema (especially pitting)
- Anasarca
- Ascites
- Pleural effusions
Nutritional Concerns
- Unexplained weight loss
- Muscle wasting
- Poor wound healing
- Prolonged catabolic states
Specific Clinical Presentations
- Frothy urine (suggesting proteinuria)
- Jaundice with ascites
- Abdominal pain with ascites (to rule out SBP)
- Unexplained hypovolemia despite adequate fluid administration
Interpretation and Clinical Significance
- Normal serum albumin: 3.5-5.0 g/dL
- Mild hypoalbuminemia: 3.0-3.5 g/dL
- Moderate hypoalbuminemia: 2.5-3.0 g/dL
- Severe hypoalbuminemia: <2.5 g/dL
Hypoalbuminemia is a powerful predictor of mortality in many conditions, particularly end-stage renal disease, cirrhosis, and critical illness 4. However, it's important to note that hypoalbuminemia alone is rarely the sole cause of edema, and other mechanisms are typically involved 5.
Important Caveats
Not for Nutritional Assessment Alone: Albumin should not be used as the sole marker of nutritional status as it is affected by many non-nutritional factors including inflammation, liver function, and protein losses 6.
Acute Phase Reactant: Albumin decreases during acute inflammation regardless of nutritional status, limiting its usefulness in acutely ill patients.
Not for Routine Screening: In the absence of specific symptoms or risk factors, routine albumin testing is not recommended.
Therapeutic Implications: While identifying hypoalbuminemia is important, albumin infusion is indicated only in specific scenarios like SBP, large volume paracentesis, hepatorenal syndrome, and plasmapheresis—not for treating hypoalbuminemia itself 7, 3.
Monitoring Response: In conditions like nephrotic syndrome, albumin levels should be monitored to assess response to treatment rather than as a diagnostic tool alone 8.
By following these guidelines for albumin testing, clinicians can appropriately identify patients at risk for complications related to hypoalbuminemia and initiate proper management strategies to improve outcomes.