At what level of severity of hypoalbuminemia (low albumin level) should correction be initiated and how should it be treated?

Management of Hypoalbuminemia: When and How to Correct

Hypoalbuminemia should be treated when serum albumin levels fall below 3.0 g/dL, with primary focus on addressing the underlying cause rather than simply administering albumin infusions. 1

Severity Classification and Clinical Significance

• Hypoalbuminemia is classified as mild (3.0-3.5 g/dL), moderate (2.5-3.0 g/dL), and severe (<2.5 g/dL) 1
• Serum albumin <3.0 g/dL is associated with increased risk of surgical complications, including surgical site infections and poor wound healing 2
• Hypoalbuminemia <3.0 g/dL is considered a significant surgical risk factor and reflects disease-associated catabolism and disease severity 2
• Low albumin is a strong predictor of mortality and morbidity across multiple conditions 1, 3

Primary Treatment Approach

• The cornerstone of treatment is identifying and addressing the underlying cause of hypoalbuminemia (inflammation, malnutrition, protein loss) rather than simply correcting the albumin level 1
• Provide adequate nutritional support, especially in malnourished patients, with protein intake of 1.2-1.3 g/kg body weight/day 2, 1
• Monitor nutritional status regularly in patients at risk of hypoalbuminemia 1
• Treat underlying inflammatory conditions when present 1, 3

When to Consider Albumin Infusion

Albumin infusion should be considered only in specific clinical scenarios:

• Large-volume paracentesis (>5L) in cirrhotic patients at a dose of 8g albumin/L of ascites removed 2
• Spontaneous bacterial peritonitis with increased serum creatinine (1.5g albumin/kg within 6 hours of diagnosis, followed by 1g/kg on day 3) 2
• Hypovolemic shock when crystalloids are insufficient, with dosage adapted to individual patient response 4
• Severe burns (usually beyond 24 hours) to maintain plasma albumin concentration around 2.5±0.5 g/dL 4
• Acute liver failure to support colloid osmotic pressure and bind excess plasma bilirubin 4

When Albumin Infusion is NOT Recommended

• For routine treatment of hypoalbuminemia in critically ill patients 1, 5
• For first-line volume replacement in most clinical scenarios 1
• In conjunction with diuretics for removal of extravascular fluid 1
• For preterm neonates with respiratory distress 1
• For patients undergoing kidney replacement therapy to prevent intradialytic hypotension 1

Dosage and Administration When Indicated

• For hypoproteinemia: The usual daily dose is 50-75g for adults and 25g for children 4
• Administration rate should not exceed 2mL per minute to avoid circulatory embarrassment and pulmonary edema 4
• Albumin should always be administered intravenously, either undiluted or diluted in 0.9% sodium chloride or 5% dextrose 4
• If sodium restriction is required, albumin should only be administered undiluted or diluted in sodium-free solutions 4

Special Considerations for Specific Conditions

Cirrhosis and Ascites

• Albumin infusion is recommended after large-volume paracentesis (>5L) at 8g/L of ascites removed 2
• In spontaneous bacterial peritonitis with increased creatinine, albumin infusion is recommended 2

Surgical Patients

• Preoperative nutritional assessment and optimization is recommended for patients with albumin <3.0 g/dL 2
• Correction of nutritional deficiency is recommended when feasible before surgery 1

Chronic Kidney Disease

• Target serum albumin equal to or greater than the lower limit of normal range (approximately 4.0 g/dL) 1
• Focus on adequate nutrition, preventing catabolic illness, and maintaining adequate dialysis clearance 1

Monitoring Response to Treatment

• Regular assessment of serum albumin levels is necessary to monitor improvement 1
• Evaluate serum albumin in the context of the patient's overall clinical status 1
• Consider measuring inflammatory markers (e.g., C-reactive protein) to identify inflammation as a cause of hypoalbuminemia 1

Potential Adverse Effects of Albumin Infusion

• Fluid overload and pulmonary edema 1, 4
• Hypotension 1
• Hemodilution requiring RBC transfusion 1
• Anaphylaxis 1
• Peripheral gangrene from dilution of natural anticoagulants 1

Common Pitfalls to Avoid

• Assuming hypoalbuminemia is solely due to nutritional deficiency when inflammation may be the primary driver 1, 3
• Focusing on albumin correction without addressing the underlying cause 1, 3
• Using albumin infusion as a first-line treatment for hypoalbuminemia without specific indications 1, 5
• Administering albumin too rapidly, which may precipitate circulatory embarrassment 4