How is low albumin (hypoalbuminemia) treated?

Treatment of Hypoalbuminemia

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

Understanding Hypoalbuminemia

• Hypoalbuminemia is common in acute and chronic illness and is associated with greater morbidity compared to patients with preserved albumin levels 2
• In the postoperative period, serum albumin levels typically decrease by 10-15 g/L due to suppressed synthesis from inflammatory cytokines and transcapillary loss 2
• Hypoalbuminemia results from multiple factors including:
  • Inflammation (causing decreased synthesis and increased catabolism) 3
  • Inadequate protein and caloric intake 3
  • Hemodilution from fluid administration 4
  • Liver dysfunction 4
  • Protein losses (urinary, peritoneal, or gastrointestinal) 5

Primary Treatment Approach

• Focus on treating the underlying cause of hypoalbuminemia rather than the low albumin level itself 1, 4
• Provide adequate nutritional support, especially in malnourished patients 1
• Address any inflammatory processes that may be contributing to hypoalbuminemia 3
• Correct fluid overload if present 4

Specific Clinical Scenarios Where Albumin Infusion May Be Considered

• Liver disease complications:

  • Large-volume paracentesis (>5L): Albumin infusion is suggested to prevent paracentesis-induced circulatory dysfunction 2, 1
  • Spontaneous bacterial peritonitis: Albumin infusion is recommended 1, 6
  • Hepatorenal syndrome: Albumin administration has moderate to high quality evidence 6

• Other potential indications (with weaker evidence):

  • Second-line and adjunctive to crystalloids for fluid resuscitation in specific conditions like intradialytic hypotension 1, 6
  • Severe and refractory edema with hypoalbuminemia not responding to other treatments 6
  • Major surgery in selected patients 1, 6
  • Fluid replacement in plasmapheresis 6

When Albumin Infusion Is Not Recommended

• Critically ill adult patients (excluding thermal injuries and ARDS): Intravenous albumin is not suggested for first-line volume replacement or to increase serum albumin levels 2
• Critically ill patients with thermal injuries or ARDS: Albumin is not suggested for volume replacement or to increase serum albumin level 2
• In conjunction with diuretics for removal of extravascular fluid 2
• Preterm neonates with respiratory distress and low serum albumin levels 2
• Patients undergoing kidney replacement therapy for prevention or treatment of intradialytic hypotension 2
• Pediatric patients undergoing cardiovascular surgery 2

Special Considerations

• In patients with heart failure and hypoalbuminemia:

  • Remove subclinical excess fluid 7
  • Perform dietary survey and consider nutritional intervention 7
  • Note that hypoalbuminemia can facilitate the onset of cardiogenic pulmonary edema 7

• In patients with renal disease:

  • CAPD patients can increase albumin synthesis to replace losses, similar to nephrotic patients with normal renal function 5
  • Hemodialysis patients may have reduced albumin synthesis due to inflammation and inadequate nutrition 5

Cautions

• Albumin infusion is expensive (approximately $130/25g USD) and has potential adverse effects including fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene 2
• Simply administering albumin to critically ill patients with hypoalbuminemia has not been shown to improve survival or reduce morbidity 3