Do you replace albumin in cases of hypoalbuminemia?

Albumin Replacement in Hypoalbuminemia

Albumin replacement is not recommended for patients with hypoalbuminemia (serum albumin of 1.2 g/dL) unless specific clinical indications are present. 1

Evidence-Based Recommendations for Albumin Use

General Principle

• Intravenous albumin should not be used solely to correct low serum albumin levels or for nutritional purposes 2
• Hypoalbuminemia is a marker of illness severity rather than a condition requiring direct treatment with albumin infusions 3

Specific Clinical Scenarios Where Albumin IS Indicated

1. Liver Disease Complications

   • Spontaneous bacterial peritonitis (SBP): Albumin (1.5 g/kg at diagnosis and 1g/kg on day 3) decreases hepatorenal syndrome incidence and improves survival 1
   • Large-volume paracentesis (>5L): Albumin is suggested to prevent paracentesis-induced circulatory dysfunction 1
   • Hepatorenal syndrome: Strong recommendation for albumin administration 2

2. Fluid Replacement in Specific Conditions

   • Plasmapheresis: Moderate to high quality evidence supports albumin use 2
   • Patients with cirrhosis and SBP with baseline serum bilirubin ≥68 μmol/L or serum creatinine ≥88 μmol/L 1

Clinical Scenarios Where Albumin is NOT Indicated

1. Critical Care Settings

   • In critically ill adult patients, albumin is not suggested for first-line volume replacement or to increase serum albumin levels 1
   • No mortality benefit found when comparing crystalloid to albumin in critical care 1

2. Kidney Disease

   • In patients undergoing kidney replacement therapy, albumin is not suggested for prevention or treatment of intradialytic hypotension 1
   • Serum albumin is a valid measure of protein-energy nutritional status in maintenance dialysis patients, but low levels should prompt evaluation for malnutrition rather than albumin replacement 1

3. Other Conditions

   • Not recommended for removal of extravascular fluid when used with diuretics 1
   • Not recommended in critically ill patients with thermal injuries or ARDS 1

Understanding Hypoalbuminemia

Causes

• Inflammation reduces albumin synthesis and increases catabolism 3
• Inadequate protein and caloric intake reduces synthesis 3
• In kidney disease, albumin loss into dialysate may contribute to hypoalbuminemia 4
• Hypoalbuminemia in heart failure is associated with increased mortality but not treated with albumin infusions 5

Clinical Significance

• Hypoalbuminemia is an independent risk factor for adverse outcomes across many disease states 4
• In maintenance hemodialysis, approximately 60% of patients have albumin concentrations <4.0 g/dL 4
• Low albumin predicts mortality in chronic kidney disease and heart failure 3, 5

Special Considerations

Pediatric Patients with Congenital Nephrotic Syndrome

• Some centers administer albumin only when clinically indicated, while others use regular infusion protocols (1-4 g/kg/day) 1
• Albumin infusions should be based on clinical indicators of hypovolemia rather than serum albumin levels 1
• Symptoms suggesting hypovolemia include prolonged capillary refill time, tachycardia, hypotension, oliguria, and abdominal discomfort 1

Monitoring Recommendations

• In dialysis patients, predialysis or stabilized serum albumin is a valid measure of protein-energy nutritional status 1
• Target albumin level equal to or greater than the lower limit of normal range (approximately 4.0 g/dL for bromcresol green method) 1
• Low albumin should prompt evaluation for protein-energy malnutrition rather than direct albumin replacement 1

Common Pitfalls to Avoid

• Treating the number instead of the patient: Administering albumin solely to correct laboratory values without addressing underlying causes 3
• Ignoring inflammation: Acute or chronic inflammation limits the specificity of serum albumin as a nutritional marker 1
• Overlooking nutritional status: Hypoalbuminemia may reflect inadequate protein and caloric intake requiring nutritional intervention rather than albumin infusion 3
• Disregarding clinical context: Patient's clinical status (comorbid conditions, dialysis modality, acid-base status, degree of proteinuria) must be examined when evaluating serum albumin levels 1