When to use albumin with diuretic therapy in hypovolemia or impaired renal function?

From the Guidelines

Albumin should be used with diuretic therapy in patients with hypovolemia or impaired renal function, specifically in those with cirrhosis and spontaneous bacterial peritonitis (SBP) or hepatorenal syndrome (HRS), as it has been shown to reduce the risk of acute kidney injury (AKI) and mortality.

Key Indications for Albumin Use

• Spontaneous bacterial peritonitis (SBP): Albumin should be administered at a dose of 1.5 g/kg on day 1 and 1 g/kg on day 3, in addition to antibiotics, to reduce the risk of AKI and mortality 1.
• Large-volume paracentesis: Albumin should be administered at a dose of 6-8 g/L to prevent post-paracentesis circulatory dysfunction (PPCD) 1.
• Hepatorenal syndrome (HRS): Albumin is used in combination with vasoconstrictors to improve renal function and reduce mortality 1.

Important Considerations

• Diuretic therapy: Albumin can be used in conjunction with diuretics to enhance their effectiveness and reduce the risk of AKI in patients with cirrhosis and ascites 1.
• Hypovolemia: Albumin can be used to expand plasma volume in patients with hypovolemia, particularly in those with cirrhosis and ascites 1.
• Renal function: Albumin should be used with caution in patients with impaired renal function, as it can exacerbate renal dysfunction in some cases 1.

Evidence Quality

The evidence supporting the use of albumin in these indications is based on moderate to low certainty of evidence, with some studies suggesting benefits in reducing AKI and mortality, while others show no significant differences 1. However, the use of albumin in these clinical scenarios is widely accepted and recommended by various guidelines.

From the FDA Drug Label

When clinical signs are those of hypoproteinemia with a fluid volume overload, Plasbumin-25 together with a diuretic may play a role in therapy In this situation a loop diuretic and 100 mL Plasbumin-25 repeated daily for 7 to 10 days may be helpful in controlling the edema and the patient may then respond to steroid treatment.

Use of albumin with diuretic therapy in hypovolemia or impaired renal function may be considered when:

• There are signs of hypoproteinemia with fluid volume overload, and a diuretic is also being used.
• The patient has acute nephrosis and is not responding to steroid therapy, in which case a loop diuretic and albumin may be helpful in controlling edema.

Key considerations:

• Use of albumin should be tailored to the individual patient's response and clinical condition.
• Caution should be exercised to avoid fluid overload, especially in patients with impaired renal function. 2 2

From the Research

Indications for Albumin Use with Diuretic Therapy

• Albumin can be used to improve the response to diuretics in patients with cirrhosis and ascites, as it has been shown to increase the cumulative rate of response to diuretic treatment and prevent recurrence of ascites 3.
• The combination of furosemide and human albumin may provide clinical benefits for select patients with diuretic-resistant edema, particularly those with recalcitrant edema or ascites and severe hypoalbuminemia 4.
• However, hypoalbuminemia may not decrease the diuretic effectiveness in patients with acute decompensated heart failure receiving continuous infusion diuretics 5.

Patient Selection

• Patients with cirrhosis and ascites may benefit from albumin infusion to improve diuretic response and prevent ascites recurrence 3.
• Patients with nephrotic syndrome and cirrhosis who are resistant to diuretics may benefit from the combination of furosemide and human albumin 4.
• Patients with severe hypoalbuminemia and diuretic-resistant edema may be considered for albumin infusion to enhance diuretic efficacy 4.

Clinical Considerations

• The use of albumin should be guided by evidence-based guidelines to reduce inappropriate uses 6.
• The cost/benefit ratio of albumin use should be considered, as it may not be favorable in all cases 3.
• The potential benefits of albumin infusion on renal function should be taken into account, particularly in patients with cirrhosis and sepsis 7.