What are the risks of administering large quantities of Intravenous (IV) albumin?

Side Effects of Large Quantities of IV Albumin

Intravenous albumin administration can cause several adverse effects including fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene from dilution of natural anticoagulants. 1

Common Adverse Events

• Fluid overload and pulmonary edema - One of the most significant risks, especially in patients with compromised cardiac or pulmonary function 1, 2
• Hypotension and tachycardia - Paradoxical hypotension can occur despite albumin being used to treat hypovolemia 2
• Hemodilution - May require RBC transfusion to correct 1
• Anaphylactic/allergic reactions - Including rash, pruritus, rigors, and pyrexia 1, 2

Risk Factors for Adverse Events

• Cirrhosis - Patients with advanced liver disease are particularly susceptible to adverse effects due to:

  • Increased capillary permeability 3
  • Higher hydrostatic pressure from hyperdynamic circulation 3
  • Compromised lymphatic drainage capacity 3

• Sepsis - Can worsen capillary leak syndrome, leading to extravasation of albumin into interstitial spaces 3, 4

• Diabetes mellitus - May increase capillary permeability, potentially worsening fluid extravasation with albumin administration 3

• Traumatic brain injury - Albumin is associated with significantly higher mortality in these patients 5

Specific Complications by Patient Population

Critical Care Patients

• Albumin administration may not be effective for first-line volume replacement and can lead to adverse effects 1
• In patients with traumatic brain injury, albumin is associated with higher mortality 5

Patients with Cirrhosis

• Higher rates of pulmonary edema observed in cirrhotic patients receiving albumin for extraperitoneal infections 1
• Circulatory overload is more common in patients with cirrhosis receiving albumin versus crystalloid 1
• In advanced cirrhosis, albumin may promote extravascular fluid accumulation rather than improving circulating volume 3

Patients on Kidney Replacement Therapy

• Despite theoretical benefits, albumin administration during kidney replacement therapy has minimal supporting data and carries risks 6
• Hyperoncotic albumin solutions may potentially precipitate or worsen acute kidney injury in patients with sepsis or shock 6

Dose-Related Considerations

• Adverse events are generally dose-dependent, with higher doses carrying greater risk 1
• Large volumes of albumin administration can lead to reverse colloid oncotic pressure, promoting fluid movement out of capillaries and worsening edema 3

Monitoring Recommendations

• Monitor for signs of fluid overload: respiratory distress, pulmonary rales, peripheral edema 2
• Watch for hypotension and tachycardia during infusion 2
• Be vigilant for signs of allergic reactions: skin changes, fever, rigors 1
• In patients with cirrhosis, carefully monitor for signs of pulmonary edema, which occurs at higher rates with albumin administration 1

Practical Considerations

• The cost of albumin (approximately $130/25g USD) should be weighed against potential risks 1
• In patients with hypoalbuminemia, addressing the underlying cause rather than simply infusing albumin is generally recommended 2
• The volume effect of albumin is not predictable and depends on capillary permeability, hydrostatic pressure, and lymphatic function 3