How to manage low albumin (hypoalbuminemia) in patients with cirrhosis?

Management of Hypoalbuminemia in Cirrhosis

Albumin administration in cirrhosis should be targeted to specific clinical scenarios rather than simply correcting low serum albumin levels, as hypoalbuminemia itself is not an indication for albumin replacement. 1

Indications for Albumin Administration in Cirrhosis

Strong Evidence-Based Indications:

1. Large-Volume Paracentesis (LVP)

   • Administer albumin at 8g per liter of ascites removed 2
   • Strong recommendation for paracentesis >5L (Level A1 evidence) 2
   • Recommendation for paracentesis <5L (Level B1 evidence) 2
   • Prevents post-paracentesis circulatory dysfunction (PICD), hyponatremia, renal impairment, and mortality 2

2. Spontaneous Bacterial Peritonitis (SBP)

   • Administer 1.5g/kg in the first 6 hours, followed by 1g/kg on the third day 2
   • Significantly decreases incidence of type 1 hepatorenal syndrome (from 30% to 10%) 1
   • Reduces mortality from 29% to 10% compared with antibiotics alone 1
   • Particularly effective in patients with baseline serum bilirubin ≥68 µmol/L (4 mg/dl) or serum creatinine ≥88 µmol/L (1 mg/dl) 1

3. Hepatorenal Syndrome (HRS)

   • Administer in conjunction with vasoconstrictors (e.g., terlipressin) 1
   • Dosage: 8g per liter of ascites extracted 2

Conditional Indications:

1. Acute-on-Chronic Liver Failure (ACLF)

   • Consider albumin administration even for paracentesis <5L 2
   • Individualized approach based on severity of liver dysfunction

2. Severe Hyponatremia in Cirrhosis

   • Low to moderate quality evidence, weak recommendation 3
   • Consider in patients with sodium <120 mEq/L 1

Important Considerations

When NOT to Use Albumin:

• Routine correction of hypoalbuminemia without complications 1, 3, 4
• Nutritional supplementation 3, 4
• Patients with mild liver failure and without renal dysfunction at diagnosis of SBP 1

Potential Adverse Effects:

• Volume overload 5
• Allergic and transfusion reactions 5
• Coagulation derangements 5
• Antibody formation 5

Management Algorithm

1. Assess the clinical scenario:

   • Is this large-volume paracentesis (>5L)?
   • Is this spontaneous bacterial peritonitis?
   • Is this hepatorenal syndrome?
   • Is this acute-on-chronic liver failure?

2. Determine albumin administration based on scenario:

   • For LVP: 8g albumin per liter of ascites removed
   • For SBP: 1.5g/kg at diagnosis, followed by 1g/kg on day 3
   • For HRS: Use with vasoconstrictors as part of treatment protocol
   • For ACLF: Consider albumin even for smaller volume paracentesis

3. Monitor for response and complications:

   • Hemodynamic parameters
   • Renal function
   • Signs of volume overload
   • Electrolyte balance, particularly sodium

Additional Management Considerations

• Dietary sodium restriction (2000 mg/day) is a mainstay of treatment for patients with cirrhosis and ascites 1
• Oral diuretics should be used in conjunction with albumin therapy 1
• Fluid restriction is generally not necessary except in cases of severe hyponatremia 1
• Avoid medications that can worsen renal function in cirrhosis, including NSAIDs, ACE inhibitors, and angiotensin II antagonists 2
• Reintroduce diuretics within 1-2 days after paracentesis 2

Conclusion

Hypoalbuminemia in cirrhosis should be managed with targeted albumin therapy for specific complications rather than routine correction of low serum albumin levels. The strongest evidence supports albumin use in large-volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome. Management should focus on treating the underlying liver disease while preventing and addressing complications with evidence-based interventions.