At what albumin level should hypoalbuminemia be corrected?

When to Correct Hypoalbuminemia

Hypoalbuminemia (serum albumin <30 g/L) should be corrected by treating the underlying cause rather than focusing on the albumin level itself, as direct albumin infusion is not recommended for most clinical scenarios except in specific conditions like large-volume paracentesis and spontaneous bacterial peritonitis. 1

Understanding Hypoalbuminemia and Its Significance

• Hypoalbuminemia is defined as serum albumin <3.5 g/dL (<35 g/L) in adults and is associated with poor clinical outcomes across multiple conditions 2
• Each 10 g/L decline in serum albumin is associated with a 137% increase in mortality risk and 89% increase in morbidity 3
• Hypoalbuminemia is a valid and clinically useful measure of protein-energy nutritional status in patients with chronic conditions such as kidney disease 4
• In the postoperative setting, serum albumin typically decreases by 10-15 g/L due to inflammatory cytokines and transcapillary loss 1

Specific Clinical Thresholds for Intervention

Surgical Patients

• Hypoalbuminemia <30 g/L is associated with higher risk of postoperative intra-abdominal sepsis in inflammatory bowel disease patients 4
• Preoperative albumin assessment is recommended for risk stratification in cardiac surgery patients (Class IIa, level C-LD) 4
• Correction of nutritional deficiency is recommended when feasible before cardiac surgery (Class IIa, level C-LD) 4

Liver Disease

• In hospitalized patients with decompensated cirrhosis, hyperoncotic albumin to target a level >30 g/L showed no improvement in outcomes (infections, kidney dysfunction, or death) compared to no albumin 4
• Albumin infusion is recommended for patients with spontaneous bacterial peritonitis and for preventing paracentesis-induced circulatory dysfunction during large-volume paracentesis (>5L) 1

Chronic Kidney Disease

• A predialysis or stabilized serum albumin equal to or greater than the lower limit of the normal range (approximately 4.0 g/dL for the bromcresol green method) is the outcome goal 4
• Approximately 60% of hemodialysis patients have albumin concentrations <4.0 g/dL, which may be partially due to albumin loss during dialysis 5

When NOT to Correct Hypoalbuminemia with Albumin Infusion

• Albumin infusion is not recommended for:
  • First-line volume replacement in critically ill adult patients 1
  • Increasing serum albumin levels in critically ill patients (excluding thermal injuries and ARDS) 1
  • Use in conjunction with diuretics for removal of extravascular fluid 1
  • Preterm neonates with respiratory distress and low albumin levels 1
  • Prevention or treatment of intradialytic hypotension 1
  • Pediatric patients undergoing cardiovascular surgery 1

Recommended Approach to Hypoalbuminemia

1. Identify and treat the underlying cause 1

   • Inflammation
   • Malnutrition
   • Protein loss (nephrotic syndrome, protein-losing enteropathy)
   • Decreased synthesis (liver disease)

2. Provide nutritional support 4, 1

   • Especially important in malnourished patients
   • Nutritional support alone is unlikely to restore albumin levels while inflammation or sepsis persists 4

3. Consider albumin infusion only in specific scenarios 1

   • Spontaneous bacterial peritonitis
   • Large-volume paracentesis (>5L)

4. Monitor for improvement

   • Regular assessment of serum albumin levels
   • Evaluate clinical response to treatment of underlying condition

Cautions and Considerations

• Albumin infusion is expensive (approximately $130/25g USD) 1
• Potential adverse effects include fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene 1
• Postoperative albumin administration to maintain serum albumin ≥3 g/dL has not shown additional benefits in liver transplant patients 6
• Hypoalbuminemia can mask other laboratory abnormalities such as anion gap acidosis 7