When is albumin supplementation recommended and what is the typical dose for treating hypoalbuminemia?

Albumin Supplementation for Hypoalbuminemia: Recommendations and Dosing

Albumin supplementation is generally not recommended for the routine treatment of hypoalbuminemia alone, as it does not improve patient outcomes and should be reserved for specific clinical scenarios where evidence supports its use. 1

When Albumin Supplementation Is NOT Recommended

• Albumin should not be used for first-line volume replacement or to increase serum albumin levels in critically ill adult patients (excluding those with thermal injuries and ARDS) 1
• Albumin is not recommended for routine treatment of hypoalbuminemia in neonatal and pediatric critical care 1
• Albumin should not be administered for nutritional purposes or to simply correct low albumin levels without addressing the underlying cause 2, 3
• Albumin is not recommended for routine use in cardiovascular surgery or kidney replacement therapy 1

When Albumin Supplementation May Be Considered

Strong Evidence-Based Indications:

• Patients with cirrhosis undergoing large-volume paracentesis (>5L) 1, 4
• Patients with cirrhosis and spontaneous bacterial peritonitis 1, 4
• Fluid replacement in plasmapheresis 2, 3
• Treatment of type 1 hepatorenal syndrome (in combination with vasoconstrictors) 4, 3

Conditional Indications (Weaker Evidence):

• As second-line and adjunctive to crystalloids for fluid resuscitation in septic shock 4, 2
• Intradialytic hypotension (when other measures have failed) 1, 4
• Severe and refractory edema with hypoalbuminemia not responding to other treatments 2, 5
• Congenital nephrotic syndrome with clinical indicators of hypovolemia 1

Dosing Recommendations When Indicated

For Cirrhosis Complications:

• Large-volume paracentesis: 6-8 g of albumin per liter of ascites removed 4, 3
• Spontaneous bacterial peritonitis: 1.5 g/kg on day 1, followed by 1 g/kg on day 3 4, 3

For Congenital Nephrotic Syndrome:

• In patients with severe disease requiring regular infusions: 1-4 g/kg daily, with frequency based on clinical indicators of hypovolemia rather than serum albumin levels 1
• Consider reducing dose and frequency as chronic kidney disease progresses 1

For Intradialytic Hypotension:

• 25% albumin (100 mL) during dialysis sessions 1

Monitoring During Albumin Administration

• Monitor for signs of fluid overload: respiratory distress, pulmonary rales, peripheral edema 6
• Watch for hypotension and tachycardia during infusion 6
• Be vigilant for allergic reactions: skin changes, fever, rigors 6
• Consider administering furosemide (0.5-2 mg/kg) at the end of albumin infusions in patients at risk for fluid overload 1, 6

Adverse Effects of Albumin Administration

• Fluid overload and pulmonary edema, especially in patients with compromised cardiac or pulmonary function 6
• Hypotension despite albumin being used to treat hypovolemia 6
• Hemodilution requiring RBC transfusion 6
• Anaphylactic/allergic reactions 6
• Peripheral gangrene from dilution of natural anticoagulants 1, 6

Cost Considerations

• Albumin is expensive (approximately $130/25g in US dollars) compared to crystalloids 1, 6
• The high cost should be weighed against potential benefits, especially when used for indications with limited evidence 6, 2

Key Takeaway

Addressing the underlying cause of hypoalbuminemia is more important than simply correcting low albumin levels. The primary treatment approach should focus on treating the underlying condition (infection, malnutrition, liver disease, etc.) rather than albumin supplementation 4, 5.