How to treat hypoalbuminemia?

Treatment of Hypoalbuminemia

The primary approach to treating hypoalbuminemia should focus on identifying and treating the underlying cause rather than simply correcting the low albumin level itself. 1

Understanding Hypoalbuminemia

• Hypoalbuminemia is common in acute and chronic illness and is associated with greater morbidity compared to patients with normal albumin levels 1
• Low serum albumin is a powerful predictor of mortality in patients with chronic conditions, with a decrease of 1.0 g/dL in serum albumin increasing the odds of morbidity by 89% and mortality by 137% 1
• Hypoalbuminemia results from the combined effects of inflammation, inadequate protein and caloric intake, and increased albumin loss 2
• In the postoperative period, serum albumin levels typically decrease by 10-15 g/L due to inflammatory cytokines and transcapillary loss 1

Primary Treatment Approach

• Focus on treating the underlying cause of hypoalbuminemia rather than the low albumin level itself 1, 3
• Provide adequate nutritional support, especially in malnourished patients, with protein intake of 1.2-1.3 g/kg body weight/day 1, 3
• Address inflammation when present, as it reduces albumin synthesis and increases catabolism 1, 2
• Prevent and treat catabolic illness that may contribute to hypoalbuminemia 1

When Albumin Infusion May Be Considered

• Albumin infusion is recommended for patients with cirrhosis undergoing large-volume paracentesis (>5L) at a dose of 8g albumin/L of ascites removed 1, 3
• Albumin infusion is recommended for patients with spontaneous bacterial peritonitis, particularly those with increased serum creatinine 1, 3
• The threshold for considering albumin infusion is generally when serum albumin levels fall below 2.5 g/dL, particularly when associated with clinical symptoms of hypovolemia 1

When Albumin Infusion Is Not Recommended

• Intravenous albumin is not recommended for first-line volume replacement or to increase serum albumin levels in critically ill adult patients (excluding thermal injuries and ARDS) 1, 3
• Albumin infusion is not recommended in conjunction with diuretics for removal of extravascular fluid 1
• Albumin infusion is not recommended for preterm neonates with respiratory distress and low serum albumin levels 1
• Albumin infusion is not recommended for patients undergoing kidney replacement therapy for prevention or treatment of intradialytic hypotension 1, 3
• Albumin infusion is not recommended for pediatric patients undergoing cardiovascular surgery 1
• Simply administering albumin to critically ill patients with hypoalbuminemia has not been shown to improve survival or reduce morbidity 2, 4, 5

Special Considerations for Specific Conditions

Surgical Patients

• Preoperative albumin assessment is recommended for risk stratification in cardiac surgery patients 1
• Hypoalbuminemia <3.0 g/dL is associated with increased risk of surgical complications, including surgical site infections and poor wound healing 1
• Correction of nutritional deficiency is recommended when feasible before cardiac surgery 1

Dialysis Patients

• For dialysis patients, aim for a predialysis or stabilized serum albumin equal to or greater than the lower limit of normal range (approximately 4.0 g/dL) 1
• Maintain adequate dialysis clearance (Kt/Vurea) 1
• Monitor normalized protein nitrogen appearance (nPNA) with a target of ≥0.9 g/kg/day 1

Heart Failure Patients

• In heart failure patients with hypoalbuminemia, subclinical excess fluid should be removed 6
• A dietary survey should be performed, and renutrition may be indicated 6

Potential Adverse Effects of Albumin Infusion

• Fluid overload and pulmonary edema, especially in patients with compromised cardiac or pulmonary function 7
• Hypotension and tachycardia can occur despite albumin being used to treat hypovolemia 7
• Hemodilution requiring RBC transfusion 1, 7
• Anaphylactic/allergic reactions, including rash, pruritus, rigors, and pyrexia 7
• Peripheral gangrene from dilution of natural anticoagulants 1
• Albumin infusion is expensive (approximately $130/25g USD) 1, 3, 7

Common Pitfalls to Avoid

• Assuming hypoalbuminemia is solely due to nutritional deficiency when inflammation may be the primary driver 1, 2
• Focusing on correcting the albumin level rather than addressing the underlying cause 1, 3, 2
• Overlooking the impact of hypoalbuminemia on drug pharmacokinetics, especially for highly protein-bound antibiotics which may require dose adjustments 8
• Failing to monitor for signs of fluid overload when administering albumin, particularly in patients with cirrhosis or cardiac dysfunction 7