Causes and Management of Hypoalbuminemia
Hypoalbuminemia should be managed by treating the underlying cause rather than focusing solely on correcting the low albumin level itself. 1
Causes of Hypoalbuminemia
Decreased Production
- Liver disease/cirrhosis - reduced hepatic synthesis capacity 2
- Malnutrition and inadequate protein intake 1, 3
- Inflammation - inflammatory cytokines suppress albumin synthesis 1, 3
Increased Losses
- Nephrotic syndrome - urinary protein loss 4
- Protein-losing enteropathy - gastrointestinal losses 1, 5
- Burns - exudative losses through damaged skin 6
- Surgical procedures - perioperative losses can exceed half of circulating albumin 6
- Acute peritonitis, pancreatitis, mediastinitis, extensive cellulitis - sequestration of protein-rich fluids 6
Increased Distribution/Dilution
- Fluid overload/hemodilution - expands plasma volume 5, 7
- Increased vascular permeability (sepsis, inflammation) - leakage into interstitial space 1, 3
Other Factors
- Steroid therapy - increases net protein loss and drives catabolism 1
- Chronic kidney disease - multifactorial including inflammation and nutritional deficits 1, 8
- Heart failure - associated with malnutrition, inflammation, and hemodilution 5
Clinical Significance
- Hypoalbuminemia is strongly associated with increased morbidity and mortality across various conditions 1, 3
- A decrease of 1.0 g/dL in serum albumin increases odds of morbidity by 89% and mortality by 137% 1
- Serum albumin <3.0 g/dL is associated with increased risk of surgical complications 1
- In dialysis patients, low albumin is a strong predictor of mortality and morbidity 1, 8
Management Approach
Primary Treatment Strategy
- Identify and treat the underlying cause rather than just correcting albumin levels 1, 8
- Provide adequate nutritional support, especially in malnourished patients 1
- For dialysis patients, aim for albumin ≥4.0 g/dL (using bromcresol green method) 1, 8
Nutritional Support
- Protein intake of 1.2-1.3 g/kg body weight/day for clinically stable chronic peritoneal dialysis patients 1, 8
- Regular nutritional assessment by a dietitian, especially for patients on long-term steroids 1
- Monitor normalized protein nitrogen appearance (nPNA) with target ≥0.9 g/kg/day in dialysis patients 1
Albumin Infusion Indications
- Spontaneous bacterial peritonitis in cirrhosis 1, 4, 2
- Large-volume paracentesis (>5L) in cirrhotic patients at 8g albumin/L of ascites removed 1, 6, 2
- Type 1 hepatorenal syndrome 4, 2
- Fluid resuscitation in select patients with sepsis 6, 4
- Therapeutic plasmapheresis with large volume plasma exchange 4
- Neonatal hemolytic disease - 1 g/kg body weight about 1 hour prior to exchange transfusion 6
- Acute nephrosis unresponsive to cyclophosphamide or steroid therapy - 100 mL Plasbumin-25 daily for 7-10 days 6
- Shock or hypotension during renal dialysis - about 100 mL, with caution to avoid fluid overload 6
Monitoring Recommendations
- Regular assessment of serum albumin levels to monitor improvement 1
- For dialysis patients, measure albumin at least every 4 months 1, 8
- Consider measuring C-reactive protein to identify inflammation in patients with low albumin 1
- Monitor for stable or rising albumin values as a positive indicator 1, 8
When Albumin Infusion Is Not Recommended
- Chronic nephrosis - infused albumin is promptly excreted by kidneys 6
- Hypoproteinemic states associated with chronic cirrhosis, malabsorption, protein-losing enteropathies, pancreatic insufficiency, and undernutrition - not justified as a source of protein nutrition 6
- First-line volume replacement in critically ill adult patients (excluding thermal injuries and ARDS) 1
- In conjunction with diuretics for removal of extravascular fluid 1
- For preterm neonates with respiratory distress and low serum albumin levels 1
- For prevention or treatment of intradialytic hypotension in patients undergoing kidney replacement therapy 1
- For pediatric patients undergoing cardiovascular surgery 1