How to correct low albumin levels and what to order?

How to Correct Low Albumin Levels and What to Order

Focus on treating the underlying cause of hypoalbuminemia rather than administering albumin infusions, which are expensive, not evidence-based for routine correction, and do not improve outcomes in most clinical scenarios. 1, 2

Diagnostic Workup to Order

Initial Laboratory Assessment:

• Serum albumin level (use laboratory-specific reference ranges; target ≥4.0 g/dL by bromcresol green method) 3
• C-reactive protein or other acute-phase reactants to identify inflammation as the driver 3
• Complete metabolic panel to assess kidney and liver function 1
• Urinalysis with urine protein-to-creatinine ratio to detect protein-losing nephropathy 2
• Consider stool alpha-1 antitrypsin if protein-losing enteropathy suspected 2

Nutritional Assessment:

• Normalized protein nitrogen appearance (nPNA) with target ≥0.9 g/kg/day 3
• Dietary intake evaluation by renal dietitian 3

Treatment Algorithm Based on Underlying Cause

Step 1: Identify and Treat the Primary Cause

Inflammation-Driven Hypoalbuminemia:

• Inflammation increases capillary permeability, expands albumin distribution volume, and shortens albumin half-life despite increased synthesis rates 4
• Treat the underlying inflammatory condition (infection, autoimmune disease, malignancy) 5, 4
• Albumin infusion does NOT improve outcomes when inflammation is the primary driver 5, 6

Malnutrition-Related Hypoalbuminemia:

• Increase dietary protein intake to 1.2-1.3 g/kg body weight/day in stable patients 3, 2
• Involve renal dietitian for personalized nutritional planning 3, 2
• Monitor nPNA with target ≥0.9 g/kg/day 3

Protein Loss Syndromes:

• Nephrotic syndrome: Treat underlying kidney disease 2
• Protein-losing enteropathy: Address gastrointestinal pathology 2, 7
• Burns: Manage according to burn protocols 1

Liver Dysfunction:

• Optimize liver function and treat underlying liver disease 7
• See specific indications below for cirrhosis-related albumin use 1

Step 2: Optimize Dialysis Adequacy (If Applicable)

For Peritoneal Dialysis Patients:

• Maintain Kt/Vurea at recommended levels 3
• Monitor serum albumin at least every 4 months 3, 2
• Target predialysis albumin ≥4.0 g/dL 3
• Ensure protein intake of 1.2-1.3 g/kg/day 3

Critical Point: In patients with high urea levels, prioritize effective dialysis to remove excess urea rather than albumin administration 1

Step 3: Prevent and Treat Catabolic Illness

• Address active infections, sepsis, or other catabolic states 3
• Catabolic illness reduces albumin synthesis and increases degradation even with adequate protein intake 3, 5
• Corticosteroids drive catabolism and worsen hypoalbuminemia—use for shortest duration possible 1

When Albumin Infusion IS Indicated (Specific Scenarios Only)

Liver Disease with Complications:

• Large-volume paracentesis >5L: Give 8g albumin per liter of ascites removed 1, 2
• Spontaneous bacterial peritonitis with elevated creatinine 1, 2

NOT Indicated For:

• Routine correction of low albumin levels 1, 2, 6
• First-line volume replacement in critically ill patients (excluding thermal injuries and ARDS) 1
• Preterm neonates with respiratory distress 1
• Intradialytic hypotension prevention 1
• Pediatric cardiovascular surgery 1
• Conjunction with diuretics for fluid removal 1

Monitoring Strategy

Frequency:

• Check serum albumin at least every 4 months in dialysis patients 3, 2
• More frequent monitoring if albumin is declining 8

Interpretation:

• A decrease of 0.1 g/dL/month is clinically significant and indicates higher risk even if absolute value remains normal 3, 8
• Each 0.1 g/dL decrease associates with 5% increased risk of technique failure, 5% more hospitalization days, and 6% increased mortality risk in dialysis patients 8
• Evaluate trends rather than isolated values 2, 8
• Rising or stable albumin indicates anabolic state and improving protein stores 3

Common Pitfalls to Avoid

• Do not assume hypoalbuminemia equals malnutrition—inflammation is often the primary driver 1, 5, 4
• Do not routinely infuse albumin to "correct the number"—this is expensive (~$130/25g), not evidence-based, and carries risks including fluid overload, hypotension, hemodilution, anaphylaxis, and peripheral gangrene 1, 2, 6
• Do not ignore small but progressive decreases (≥0.1 g/dL) even within normal range 3, 8
• Do not overlook comorbid conditions (diabetes, age, peritoneal transport characteristics) that independently predict albumin levels 3

Clinical Significance

• Each 1.0 g/dL decrease in serum albumin increases odds of morbidity by 89% and mortality by 137% 1
• Hypoalbuminemia <3.0 g/dL significantly increases surgical complications including infections and poor wound healing 1
• Low albumin is a powerful predictor of cardiovascular mortality in chronic disease 5