How is hypoalbuminemia managed with albumin replacement therapy?

Management of Hypoalbuminemia with Albumin Replacement Therapy

Albumin replacement is not recommended for the routine treatment of hypoalbuminemia alone, as there is weak evidence supporting its use and it does not improve clinical outcomes. 1

Appropriate Indications for Albumin Replacement

Albumin replacement therapy should be limited to specific clinical scenarios:

Recommended Uses:

• Liver disease complications:

  • Large-volume paracentesis (>5L): 6-8g albumin per liter of ascitic fluid removed 1
  • Spontaneous bacterial peritonitis: 1.5g/kg on day 1, followed by 1g/kg on day 3 1
  • Hepatorenal syndrome (with vasoconstrictors) 1
  • Acute liver failure (to support colloid osmotic pressure and bind excess bilirubin) 2

• Other specific indications:

  • Emergency treatment of hypovolemic shock (when crystalloids are insufficient) 2
  • Burn therapy (beyond 24 hours to maintain plasma colloid osmotic pressure) 2
  • Second-line fluid in septic shock when large volumes of crystalloids are required 1
  • Cardiopulmonary bypass (as part of priming solution) 2
  • Neonatal hemolytic disease (1g/kg body weight about 1 hour prior to exchange transfusion) 2
  • Sequestration of protein-rich fluids (peritonitis, pancreatitis, mediastinitis) 2

Not Recommended For:

• Chronic nephrosis
• Chronic cirrhosis without specific complications
• Malabsorption
• Protein-losing enteropathies
• Undernutrition
• Routine use in most ICU patients 1

Evidence Against Routine Use in Hypoalbuminemia

Multiple studies demonstrate no benefit in mortality or complication rates when albumin is given solely to correct low albumin levels:

• A prospective, randomized trial of 40 hypoalbuminemic critically ill patients showed no clinical benefit from albumin therapy when assessing mortality (39% vs 27%, treatment vs control) or major complication rates (89% vs 77% of patients) 3

• The International Collaboration for Transfusion Medicine Guidelines (ICTMG) and American College of Chest Physicians recommend against routine treatment of hypoalbuminemia alone 1

Proper Approach to Hypoalbuminemia

The correct approach to managing hypoalbuminemia includes:

1. Identify and treat the underlying cause of hypoalbuminemia 1
2. Provide nutritional support to address protein deficiency if present 1
3. Control underlying inflammation 1
4. Consider albumin only for specific indications as outlined above

Administration Guidelines When Indicated

When albumin administration is indicated:

• Dosage:

  • Adults: 50-75g daily when indicated
  • Children: 25g daily when indicated 2

• Administration rate:

  • Should not exceed 2 mL per minute in hypoproteinemic patients to avoid circulatory embarrassment and pulmonary edema 2
  • Always administer by intravenous infusion 2

• Formulation options:

  • May be administered undiluted or diluted in 0.9% Sodium Chloride or 5% Dextrose in Water
  • If sodium restriction is required, administer either undiluted or diluted in sodium-free solutions like 5% Dextrose in Water 2

Risks and Considerations

Administering albumin carries several risks:

• Fluid overload and pulmonary edema
• Hypotension/tachycardia
• Allergic reactions
• Fever and rigors
• Increased cost without clinical benefit 1

Special Considerations

• Drug interactions: Hypoalbuminemia affects pharmacokinetics of highly protein-bound drugs, potentially requiring dose adjustments and therapeutic drug monitoring 4

• Renal failure patients: In dialysis patients with volume overload and reduced effective arterial volume, albumin administration may help increase intravascular oncotic pressure to mobilize edema fluid 5

• Liver transplantation: A study of patients following living-related liver transplantation showed no significant benefit from maintaining serum albumin ≥3 g/dL compared to no correction 6

While hypoalbuminemia is strongly associated with poor clinical outcomes, this association appears to be a marker of disease severity rather than a causative factor that can be effectively addressed through albumin supplementation alone 7.