What is the treatment approach for hypoalbuminemia?

Treatment Approach for Hypoalbuminemia

The treatment of hypoalbuminemia should focus on addressing the underlying cause rather than simply correcting the low albumin level, as albumin infusion is not recommended for routine treatment of hypoalbuminemia alone. 1, 2

Understanding Hypoalbuminemia

• Hypoalbuminemia is a common finding in critically ill patients and is associated with higher morbidity and mortality rates compared to patients with normal serum albumin levels 3
• Serum albumin concentration is determined by its rate of synthesis, catabolic rate, external losses, and redistribution between vascular and extravascular spaces 4
• Hypoalbuminemia primarily reflects underlying inflammatory states, which interfere with adequate responses to events like surgery or chemotherapy 5

Causes of Hypoalbuminemia

• Inflammation: Increases capillary permeability and escape of serum albumin, leading to expansion of interstitial space 5
• Malnutrition: Associated with low protein intake, though its development in response to malnutrition alone is slow compared to inflammatory causes 2
• Liver dysfunction: Impairs albumin synthesis 2
• Protein losses: Through kidney disease, protein-losing enteropathy, or peritoneal dialysis 4
• Dilution with crystalloids: Can rapidly decrease albumin concentration 2

Treatment Approach

First-line: Treat the Underlying Cause

• Identify and treat the primary condition causing hypoalbuminemia 2
• Focus on correcting ongoing inflammation rather than albumin infusion 5
• Provide adequate nutritional support, especially in malnourished patients 1

Specific Clinical Scenarios

Cirrhosis with Complications

• Albumin infusion is recommended for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis 1, 6
• For patients with hyponatremia and cirrhosis:
  • Moderate hyponatremia (120-125 mEq/L): Trial of fluid restriction to 1,000 mL/day 1
  • Severe hyponatremia (<120 mEq/L): More severe fluid restriction together with albumin infusion 1

Congenital Nephrotic Syndrome

• Base albumin infusion frequency and dosage on clinical indicators of hypovolaemia rather than serum albumin levels 1
• For patients with severe disease, daily albumin infusions of up to 1–4 g/kg may be initiated 1
• As chronic kidney disease progresses, albumin dose may be reduced and infusions made less frequent or stopped 1

Critically Ill Patients

• Intravenous albumin is not suggested for first-line volume replacement or to increase serum albumin levels in critically ill adult patients 1
• Supportive measures, including intravenous fluid resuscitation, albumin supplementation, and electrolyte replacement, should be provided to all patients with severe C. difficile infection 1

Surgical Patients

• Preoperative hypoalbuminemia (<30 g/L) is associated with a higher risk of postoperative intra-abdominal sepsis 1
• The evidence to support the use of intravenous albumin to correct hypoalbuminemia before surgery is weak 1
• Treatment should focus on underlying sepsis control and inflammation management 1

When Albumin Infusion May Be Considered

• Fluid replacement in plasmapheresis and specific liver diseases (moderate to high quality evidence) 6
• As second-line and adjunctive to crystalloids for fluid resuscitation in specific conditions (low to moderate quality evidence):
  • Hypovolemic shock
  • Sepsis and septic shock
  • Severe burns
  • Intradialytic hypotension
  • Major surgery
  • Severe and refractory edema with hypoalbuminemia 6

Important Considerations

• Albumin infusion has not been shown to diminish fluid requirements, infection rates, or mortality in the intensive care unit 5
• Management should be based on correcting the causes of ongoing inflammation rather than infusion of albumin 5
• Several ongoing clinical trials are evaluating the role of albumin in various clinical scenarios, which may provide more definitive guidance in the future 1

Common Pitfalls to Avoid

• Treating the laboratory value rather than the patient's clinical condition 2
• Using albumin infusion as a nutritional supplement, which is not recommended 6
• Failing to identify and address the underlying cause of hypoalbuminemia 2, 5
• Overreliance on albumin infusion without addressing inflammation or other primary causes 5