Which type of albumin, 5% or 25%, is recommended for clinical use?

Albumin 25% is Recommended Over 5% for Most Clinical Applications

For most clinical applications requiring albumin administration, 25% albumin solution is recommended over 5% albumin due to its superior volume expansion efficiency and reduced fluid overload risk.

Mechanism of Action and Volume Expansion Properties

• Both 5% and 25% albumin solutions provide similar plasma volume expansion when the same amount of albumin is administered, but through different mechanisms 1, 2
• 25% albumin draws additional fluid from the interstitial space into the intravascular compartment, resulting in approximately twice the volume expansion relative to the infused volume 2
• 5% albumin solution contains more free water, but approximately one-third of this volume quickly leaks out of the plasma due to differences in colloid osmotic pressure 2

Clinical Applications and Recommendations

Paracentesis

• For large-volume paracentesis (>5L), the European Association for the Study of the Liver specifically recommends using 20% or 25% albumin solution at a dose of 8g per liter of ascites removed 3
• This concentrated formulation reduces the risk of fluid overload in cirrhotic patients who already have compromised fluid handling 3

Intradialytic Hypotension

• A 2021 randomized crossover trial found that 25% albumin improved hypotension, lowest intradialytic systolic BP, and ultrafiltration rate compared to saline in patients with serum albumin <30 g/L 4
• The concentrated 25% formulation is preferred in this setting to avoid additional fluid administration in patients already experiencing fluid overload 4

Cirrhosis and Spontaneous Bacterial Peritonitis

• For spontaneous bacterial peritonitis, high-dose albumin is recommended (1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3) 3, 5
• 25% albumin is preferred in this context to minimize the volume of fluid administered to cirrhotic patients 3

Cardiac Surgery

• In cardiac surgery patients, practice patterns vary, but there is increasing preference for 25% albumin as an adjunct fluid to crystalloids, particularly among surgeons 6
• The reduced fluid volume with 25% albumin is advantageous in cardiac surgery patients where fluid overload can be detrimental 6

Practical Considerations

• One 100mL infusion of 25% albumin (25g) typically increases serum albumin levels by approximately 0.2-0.3 g/dL 5
• 25% albumin provides the same amount of albumin in one-fifth the volume compared to 5% solutions, making it more suitable for patients at risk of fluid overload 5
• The higher viscosity of 25% albumin may make administration slightly more challenging, but this is generally not a significant clinical limitation 1

Special Situations for 5% Albumin

• 5% albumin may be preferred in sepsis resuscitation as an alternative to crystalloids, though recent evidence suggests no mortality benefit and possibly higher mortality compared to balanced crystalloids 7
• Some clinicians prefer 5% albumin for its lower viscosity and ease of infusion, particularly when rapid administration is required 1
• In settings where additional free water administration is desired alongside albumin, 5% solutions may be appropriate 1

Cost Considerations

• 25% albumin is more cost-effective when considering the amount of albumin delivered per dollar 3
• The annual cost of albumin for maintenance hemodialysis is estimated at $20,000 per patient in the United States, highlighting the importance of efficient use 4

Caveats and Pitfalls

• Avoid using albumin (either concentration) as a first-line fluid in pediatric patients with severe infections, as evidence suggests potential harm 4
• Be cautious with hyperoncotic albumin (20-25%) in traumatic brain injury and some intensive care patients, as some studies suggest negative effects on outcomes 8
• Consider that the evidence base for albumin use in many clinical scenarios remains limited, and its high cost warrants judicious use 4