Why should albumin not be administered in the last hour of dialysis?

Albumin Administration During Dialysis: Timing Considerations

Albumin should not be administered during the last hour of dialysis due to reduced effectiveness for intradialytic hypotension prevention and potential loss of this expensive protein through the dialyzer membrane without providing clinical benefit. 1

Evidence Against Albumin Use in the Last Hour of Dialysis

• The International Collaboration for Transfusion Medicine Guidelines (ICTMG) recommends against albumin infusion during kidney replacement therapy for preventing or treating intradialytic hypotension or improving ultrafiltration (Conditional Recommendation, Very Low Certainty of Evidence) 1
• Administering albumin near the end of dialysis provides insufficient time for it to exert its oncotic effect and stabilize blood pressure before the session ends 2
• When given in the last hour, a significant portion of the albumin may be removed through the dialyzer membrane, resulting in wastage of an expensive resource 3, 4

Optimal Timing for Albumin Administration (When Clinically Indicated)

• If albumin is deemed necessary (despite limited evidence supporting its routine use), administration should occur at the beginning of dialysis to maximize its potential hemodynamic benefits 5
• A randomized crossover trial showed that when albumin was administered at the initiation of dialysis in hypoalbuminemic patients, it resulted in fewer episodes of hypotension compared to saline 5
• Early administration allows albumin to:
  • Enhance plasma refilling in response to ultrafiltration 4
  • Maximize its intravascular volume expansion effect throughout the session 5
  • Potentially improve ultrafiltration rates during the entire treatment 5, 6

Economic Considerations

• Albumin is an expensive blood product with estimated costs of up to $20,000 per patient annually if used regularly 2
• Administration in the last hour of dialysis represents poor resource utilization as much of the product may be removed through the dialyzer 3, 4
• The high cost without proven superiority over less expensive alternatives makes timing particularly important when albumin is used 2

Alternative Approaches for Managing Intradialytic Issues

• For preventing intradialytic hypotension, consider these evidence-based alternatives:
  • Higher dialysate calcium concentration 2
  • Lower dialysate temperature 2
  • Individualized ultrafiltration rates 2
  • Oral vasopressors like midodrine 2

Special Considerations

• In patients with severe hypoalbuminemia requiring albumin, administration should be timed at the beginning of dialysis or even between dialysis sessions to maximize benefit 4, 5
• For patients with both liver and kidney dysfunction requiring specialized albumin dialysis (e.g., MARS therapy), specific protocols for albumin circuit timing and administration exist and should be followed 7, 8

Potential Risks of Late Albumin Administration

• Administering albumin in the last hour may create a false sense of hemodynamic stability that quickly deteriorates after dialysis ends 2, 4
• The practice wastes resources without providing meaningful clinical benefit 2, 3
• There is risk of post-dialytic fluid overload if albumin administration leads to increased plasma oncotic pressure after dialysis ends 3