Should albumin be administered during dialysis in a patient with hypoalbuminemia and elevated blood urea nitrogen (BUN) levels?

Management of Hypoalbuminemia in Dialysis Patients

Albumin infusion is not recommended during dialysis for patients with hypoalbuminemia and high urea levels. 1, 2

Understanding Hypoalbuminemia in Dialysis Patients

• Hypoalbuminemia in dialysis patients is primarily caused by inflammation, inadequate protein and caloric intake, and increased albumin catabolism, rather than simply being a volume issue 3
• Low serum albumin is a strong predictor of mortality and morbidity in dialysis patients, but treating the underlying causes rather than just correcting the albumin level is the recommended approach 4
• The highest albumin level possible should be the goal for each patient, with a target of at least 4.0 g/dL (using bromcresol green method) 4

First-Line Management Approach

• Focus on treating the underlying causes of hypoalbuminemia rather than simply administering albumin 1, 3:

  • Ensure adequate nutrition monitored by a renal dietitian 4
  • Prevent and treat catabolic illness 4
  • Maintain adequate dialysis clearance (Kt/Vurea) 4
  • Address inflammation when present 4

• Aim for a protein intake of 1.2-1.3 g/kg body weight/day in clinically stable chronic peritoneal dialysis patients 4

• Monitor normalized protein nitrogen appearance (nPNA) with a target of ≥0.9 g/kg/day 4

When Albumin Infusion Is Not Recommended

• Albumin infusion is not recommended for patients undergoing kidney replacement therapy for prevention or treatment of intradialytic hypotension 1
• Intravenous albumin is not recommended for first-line volume replacement or to increase serum albumin levels in critically ill adult patients 1, 5
• Simply administering albumin to patients with hypoalbuminemia has not been shown to improve survival or reduce morbidity 3

Special Considerations for High Urea Levels

• In patients with high urea levels (270 mg/dL), the priority should be effective dialysis to remove the excess urea rather than albumin administration 4
• High urea levels indicate uremic toxicity that requires prompt and efficient dialysis, not albumin replacement 2

Monitoring Recommendations

• Monitor serum albumin concentration regularly (at least every 4 months) 4
• Evaluate serum albumin levels in the context of the patient's overall clinical status including comorbid diseases, peritoneal transport type, delivered dose of dialysis, and quality-of-life issues 4
• Consider measuring positive acute-phase proteins (e.g., C-reactive protein) to identify inflammation in patients with low serum albumin 4

Potential Risks of Albumin Administration

• Albumin infusion carries potential risks including fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene 1
• Albumin is expensive and has not demonstrated clear benefits for routine use during dialysis 2, 6
• High-flux dialysis may actually contribute to hypoalbuminemia through increased amino acid losses, which should be considered in nutritional management 7

Evidence-Based Exceptions

• While not recommended for routine use, a randomized trial showed that albumin administration before dialysis in hypoalbuminemic inpatients resulted in fewer episodes of hypotension and improved fluid removal 8
• However, this specific benefit for preventing intradialytic hypotension does not outweigh the overall recommendation against routine albumin use during dialysis for patients with hypoalbuminemia and high urea 1, 2