Does albumin infusion during dialysis improve clearance?

Albumin Infusion During Dialysis Does Not Improve Clearance

Albumin infusion during dialysis is not recommended for improving clearance as there is very low certainty of evidence supporting this practice, and it is not suggested for improving ultrafiltration or preventing intradialytic hypotension. 1

Evidence Against Albumin Use During Dialysis

• The International Collaboration for Transfusion Medicine Guidelines (2024) specifically recommends against albumin infusion during kidney replacement therapy, stating: "In patients undergoing kidney replacement therapy, intravenous albumin is not suggested for the prevention or treatment of intradialytic hypotension or for improving ultrafiltration" (Conditional Recommendation, Very Low Certainty of Evidence of Effect) 1

• Despite its theoretical benefits for maintaining oncotic pressure, albumin infusion during dialysis has not demonstrated convincing evidence of improving small-molecule clearance 1

• The high cost of albumin (estimated at $20,000 per patient annually for thrice-weekly administration) without proven superiority over less expensive alternatives makes it an economically unsustainable option 1, 2

Alternative Approaches for Managing Intradialytic Issues

• For preventing intradialytic hypotension, alternative strategies are recommended instead of albumin:

  • Higher dialysate calcium concentration 1
  • Lower dialysate temperature 1
  • Individualized ultrafiltration rates 1
  • Oral vasopressors like midodrine 1

• For patients with hypoalbuminemia, focus should be on addressing underlying causes rather than albumin infusion:

  • Ensure adequate protein intake (1.2-1.3 g/kg body weight/day) 1, 3
  • Monitor and maintain normalized protein nitrogen appearance (nPNA) of at least 0.9 g/kg/day 1
  • Regular nutritional assessment and consultation with renal dietitian 1, 3

Special Considerations and Exceptions

• While albumin is not recommended for routine use during dialysis, the FDA label indicates it may be considered in specific situations:

  • For treatment of shock or hypotension in renal dialysis patients, using approximately 100 mL of 25% albumin 4
  • Particular caution must be taken to avoid fluid overload as dialysis patients are often already fluid overloaded 4

• Hypoalbuminemia in dialysis patients should be addressed through:

  • Maintaining adequate dialysis clearance (Kt/Vurea) as recommended in guidelines 1
  • Prevention and treatment of catabolic illness 1
  • Regular monitoring of serum albumin levels (at least every 4 months) 1

Potential Risks of Albumin Use During Dialysis

• Albumin administration may contribute to fluid overload in already volume-overloaded patients 4, 2

• The practice is costly without demonstrated benefit for improving clearance or patient-important outcomes 1, 2

• Some studies suggest hyperoncotic albumin solutions may potentially worsen acute kidney injury in patients with sepsis or shock 2

• Albumin losses during dialysis may occur, particularly with newer "protein-leaking" or "medium cut-off" membranes, potentially exacerbating hypoalbuminemia 5

Conclusion on Current Evidence

• Current evidence does not support the routine use of albumin infusion during dialysis to improve clearance 1, 2

• While a 2021 randomized crossover trial showed some benefit of albumin in preventing intradialytic hypotension in hospitalized hypoalbuminemic patients, this remains insufficient to change the overall recommendation against routine use 6

• The focus should remain on optimizing dialysis parameters, nutritional status, and addressing underlying causes of hypoalbuminemia rather than albumin infusion 1, 3