When is albumin infusion appropriate?

Appropriate Indications for Albumin Infusion

Albumin infusion should primarily be reserved for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis, as these are the only well-supported clinical indications based on current guidelines. 1

Evidence-Based Indications for Albumin Use

Strongly Recommended:

• Large-Volume Paracentesis in Cirrhosis:

  • For paracentesis >5 liters, administer 8g albumin per liter of ascites removed 2
  • Infuse after paracentesis completion using 20% or 25% albumin solution 2
  • Prevents post-paracentesis circulatory dysfunction which can lead to renal impairment 2

• Spontaneous Bacterial Peritonitis (SBP):

  • Dosing: 1.5g albumin/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 2
  • Recommended by multiple gastroenterology societies including American Association for the Study of Liver Disease 1

• Hepatorenal Syndrome:

  • Use in combination with vasoconstrictors (e.g., terlipressin) 1
  • Improves outcomes in this specific complication of cirrhosis 3

FDA-Approved Indications:

• Emergency Treatment of Hypovolemic Shock:

  • Hyperoncotic albumin (25%) expands plasma volume 3-4 times the infused volume 4
  • Total dose should not exceed 2g/kg body weight in absence of active bleeding 4
  • Consider when crystalloid therapy alone is insufficient 4

• Burn Therapy:

  • May be used beyond 24 hours post-burn to maintain plasma colloid osmotic pressure 4
  • Not recommended during the first 24 hours when crystalloids are preferred 4

• Acute Liver Failure:

  • Supports colloid osmotic pressure and binds excess plasma bilirubin 4
  • Used in rapid loss of liver function with or without coma 4

• Sequestration of Protein-Rich Fluids:

  • For conditions like acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis 4
  • When third-space losses require treatment of reduced volume or oncotic activity 4

Situations Where Albumin is NOT Recommended:

• Critical Care Settings:

  • Not recommended for routine volume replacement in critically ill adults, pediatric, or neonatal patients 1
  • Not superior to crystalloids for general volume resuscitation 5
  • Specifically contraindicated in traumatic brain injury due to increased mortality 5

• Hypoalbuminemia Without Other Indications:

  • Not recommended for treatment of hypoalbuminemia alone 1
  • Serum albumin concentration does not reflect albumin function in liver disease 3

• Chronic Conditions:

  • Not justified in chronic nephrosis, chronic cirrhosis, malabsorption, protein-losing enteropathies, pancreatic insufficiency, or undernutrition 4
  • Infused albumin is promptly excreted by the kidneys in chronic nephrosis 4

• Intradialytic Hypotension:

  • Not routinely recommended despite common usage 1, 6
  • Evidence for efficacy is minimal despite high costs 6

• Cardiovascular Surgery:

  • Not recommended for routine use 1

Clinical Pearls and Pitfalls:

• Hypoalbuminemia as a Moderator:

  • Volume effectiveness of albumin appears greater when serum albumin levels are low 7
  • However, this alone is not an indication for albumin infusion 1

• Cost Considerations:

  • Albumin is significantly more expensive than crystalloids (approximately $130/25g USD) 1
  • Cost-effectiveness should be considered when alternatives exist 5

• Potential Adverse Effects:

  • Fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis 1
  • Peripheral gangrene from dilution of natural anticoagulants 1

• Special Considerations in Plasma Volume Sequestration:

  • In the first 24 hours, albumin may be lost from excessively permeable capillaries 8
  • Later, hyperoncotic albumin may be useful to restore plasma volume and reduce interstitial edema 8

The evidence for albumin use is strongest in patients with cirrhosis complications, while most other indications have conditional or weak supporting evidence. Current guidelines emphasize the need for judicious use of albumin, reserving it for specific clinical scenarios where clear benefits have been demonstrated.