What is the recommended dose and administration method for albumin infusion in adults?

Recommended Albumin Infusion Dosing and Administration Methods

For adults requiring albumin infusion, the recommended dosing and administration method depends on the specific clinical indication, with the strongest evidence supporting use in liver cirrhosis complications such as large-volume paracentesis (8g albumin/L of ascites removed) and spontaneous bacterial peritonitis (1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3). 1, 2

Specific Dosing Recommendations by Indication

Large Volume Paracentesis

• For paracentesis >5L: Administer 8g albumin per liter of ascites removed using 20% or 25% albumin solution 1, 2
• For paracentesis <5L: Consider 8g albumin per liter of ascites removed in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1
• Administer after paracentesis is completed to prevent post-paracentesis circulatory dysfunction 1, 2

Spontaneous Bacterial Peritonitis (SBP)

• For patients with SBP and increased or rising serum creatinine: Infuse 1.5g albumin/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 1, 2
• This dosing has been shown to reduce the risk of renal dysfunction by 72% and mortality by 47% in patients with SBP 1
• Use estimated dry weight for calculation, though this can be challenging in cirrhotic patients 1

Practical Administration Considerations

• Albumin is available as 20% or 25% solution (20g or 25g per 100mL, respectively) 2, 3
• One 100mL infusion of 25% albumin typically increases serum albumin by approximately 0.2-0.3 g/dL 3
• 40-60% of administered albumin remains in circulation initially, with the remainder distributing to extravascular spaces 3
• Infusion rate should be controlled to prevent fluid overload, especially in patients with compromised cardiac function 4

Important Caveats and Considerations

Potential Adverse Effects

• Fluid overload is a significant concern, particularly with higher doses 1, 2
• Some studies suggest doses exceeding 87.5g may be associated with worse outcomes due to fluid overload 1
• A recent study found that standard dose albumin (1.5g/kg followed by 1g/kg) infused over 6 hours was not tolerated by patients, with all patients developing symptomatic circulatory overload 4
• Other potential adverse effects include hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene 2

Efficacy Considerations

• The effect of albumin infusion is transient due to redistribution and increased degradation 3
• Albumin infusions significantly increase albumin degradation rates - a study showed that 58% of infused albumin was accounted for by increased degradation 3
• A 15% increase in serum albumin concentration leads to a 39% increase in albumin degradation 3

Non-Recommended Uses

• Albumin is not recommended for routine volume replacement in critically ill adults, pediatric, or neonatal patients 2
• Not recommended for treatment of hypoalbuminemia alone 2
• Not recommended for routine use in cardiovascular surgery 2

Emerging Evidence

• Recent research suggests albumin infusion may be safe and effective even in patients without AKI and SBP, showing resolution of infection, hyponatremia, hepatic encephalopathy, and acute-on-chronic liver failure 5
• Long-term outpatient albumin therapy is being investigated, with some studies showing potential benefits in reducing hospitalizations and mortality in patients with refractory ascites 1
• However, current guidelines do not yet recommend outpatient albumin administration for patients with ascites due to cirrhosis 1