What are the indications for albumin?

Evidence-Based Indications for Albumin Administration

Based on current evidence, albumin is only recommended for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis, while it is not recommended for most other clinical scenarios where it is commonly used. 1

Strong Evidence-Based Indications

• Cirrhosis with Large-Volume Paracentesis: Albumin is recommended for patients undergoing large-volume paracentesis (>5L) to prevent circulatory dysfunction and reduce mortality 2, 3, 4
• Spontaneous Bacterial Peritonitis: Albumin administration significantly reduces mortality and the risk of developing hepatorenal syndrome in patients with spontaneous bacterial peritonitis 2, 3, 5
• Emergency Treatment of Hypovolemic Shock: Albumin may be used when patients require large volumes of crystalloids, though it is not first-line therapy 4, 6

Conditional Indications with Moderate Evidence

• Sepsis and Septic Shock: Albumin may be used as a second-line fluid for resuscitation in septic patients requiring large volumes of crystalloids 3, 6
• Hepatorenal Syndrome: Often used with terlipressin, though current evidence is insufficient for a strong recommendation 3, 7
• Burn Therapy: May be used beyond 24 hours after thermal injury to maintain plasma colloid osmotic pressure 4, 6

Other FDA-Approved Indications

• Cardiopulmonary Bypass: Used in pump priming to achieve a hematocrit of 20% and plasma albumin concentration of 2.5 g/100 mL 4
• Acute Liver Failure: May support colloid osmotic pressure and bind excess plasma bilirubin 4
• Neonatal Hemolytic Disease: May be given prior to exchange transfusion to bind free bilirubin 4
• Sequestration of Protein-Rich Fluids: Used in conditions like acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis 4
• Erythrocyte Resuspension: May be required during certain types of exchange transfusion 4
• Acute Nephrosis: May help control edema in patients not responding to cyclophosphamide or steroid therapy 4
• Renal Dialysis: May be valuable in treating shock or hypotension during dialysis 4

Not Recommended Uses

• Critically Ill Adult Patients: Not recommended for first-line volume replacement or to increase serum albumin levels (excluding thermal injuries and ARDS) 1
• Hypoalbuminemia Without Specific Indications: Not recommended for treatment of hypoalbuminemia alone 2, 6, 8
• Nutritional Supplementation: Not justified as a source of protein nutrition 4, 6
• Chronic Nephrosis: Infused albumin is promptly excreted by the kidneys with no relief of chronic edema 4
• Chronic Cirrhosis Without Complications: Not recommended for hypoproteinemic states associated with chronic cirrhosis without specific complications 4

Potential Adverse Effects

• Fluid overload, especially in patients with compromised cardiac function 2, 9
• Hypotension during rapid administration 2, 9
• Hemodilution requiring RBC transfusion 2
• Anaphylaxis (rare) 2
• Peripheral gangrene from dilution of natural anticoagulants 2
• Pulmonary edema, particularly in patients with cirrhosis 9

Clinical Considerations

• Albumin is more expensive than crystalloids (approximately $130/25g in US dollars) 2
• Available in different concentrations (typically 5%, 20%, or 25%) with different volume expansion properties 2, 4
• Hyperoncotic albumin (20-25%) expands plasma volume by 3-4 times the volume administered 4
• In dehydrated patients, additional crystalloids must be given or 5% albumin should be used instead of 25% 4
• The total dose should not exceed the level of albumin found in the normal individual (about 2 g per kg body weight) in the absence of active bleeding 4

Ongoing Research

Multiple large randomized clinical trials are currently investigating albumin use in:

• Hypoalbuminemic patients with community-acquired pneumonia 2
• Septic shock 2
• High-risk cardiac surgery 2
• Long-term administration for decompensated cirrhosis with ascites 2
• Acute kidney injury requiring kidney replacement therapy 2