What is the management approach for a patient with hypoalbuminemia?

Management of Hypoalbuminemia

The primary approach to treating hypoalbuminemia should focus on identifying and addressing the underlying cause rather than simply correcting the low albumin level itself. 1

Evaluation of Hypoalbuminemia

• Hypoalbuminemia (serum albumin <3.5 g/dL) is associated with poor clinical outcomes across multiple conditions and serves as an indicator of future mortality risk 2, 3
• Low albumin levels may result from:
  • Malnutrition and inadequate protein intake 2, 1
  • Inflammation (albumin is a negative acute-phase reactant) 2
  • Increased losses (nephrotic syndrome, protein-losing enteropathy, dialysis) 4, 5
  • Hemodilution 6
  • Decreased synthesis (liver dysfunction) 3
• When evaluating hypoalbuminemia, measure inflammatory markers (C-reactive protein, alpha-1 acid glycoprotein) to distinguish between nutritional deficiency and inflammatory causes 2

Treatment Strategies

Nutritional Support

• Provide adequate nutritional support with emphasis on protein intake, especially in malnourished patients 1
• For patients with chronic kidney disease, nutritional counseling should be provided to maintain adequate protein intake 2
• Monitor nutritional status regularly in patients requiring long-term treatments that may affect albumin levels (e.g., steroids) 1

Treatment of Underlying Conditions

• Address inflammatory conditions that may be causing hypoalbuminemia 2
• Manage underlying diseases such as liver dysfunction, heart failure, or nephrotic syndrome 6, 5
• For surgical patients with hypoalbuminemia, correction of nutritional deficiency is recommended when feasible before surgery 1

Albumin Infusion: When to Consider

• Albumin infusion is suggested for patients with liver disease complications undergoing large-volume paracentesis (>5L) 1
• Albumin infusion is recommended for patients with spontaneous bacterial peritonitis 1
• In hypoalbuminemic dialysis patients with volume overload and reduced effective arterial volume, albumin administration may help mobilize edema fluid 5

When Albumin Infusion Is Not Recommended

• Albumin infusion is not recommended for:
  • First-line volume replacement in critically ill patients 1
  • Increasing serum albumin levels in critically ill patients (excluding specific conditions) 1
  • Use with diuretics for removal of extravascular fluid 1
  • Preterm neonates with respiratory distress and low albumin levels 1
  • Patients undergoing kidney replacement therapy for prevention of intradialytic hypotension 1
  • Pediatric patients undergoing cardiovascular surgery 1

Monitoring and Goals

• For chronic kidney disease patients, aim for serum albumin equal to or greater than the lower limit of normal range (approximately 4.0 g/dL) 2
• In surgical patients, monitor albumin levels as hypoalbuminemia (<3.0 g/dL) is associated with increased risk of surgical site infections and complications 2, 1
• Regular assessment of serum albumin levels is necessary to monitor treatment effectiveness 2

Special Considerations

• In heart failure patients with hypoalbuminemia, subclinical excess fluid should be removed 6
• For patients on hemodialysis, consider dialyzer selection as newer membranes may increase albumin losses 4
• Be aware that albumin infusion carries potential adverse effects including fluid overload, hypotension, hemodilution requiring RBC transfusion, and anaphylaxis 1
• Hypoalbuminemia in surgical patients serves as a prognostic indicator but correcting it with albumin infusion alone may not improve outcomes 3

Prognosis

• A decrease of 1.0 g/dL in serum albumin increases the odds of morbidity by 89% and mortality by 137% 1
• Hypoalbuminemia is an independent predictor of incident heart failure in end-stage renal disease and elderly patients 6
• Low preoperative albumin increases risk of surgical site infections and other complications 2