What is the protocol for albumin infusion in patients with hypoalbuminemia?

Albumin Infusion Protocol

Albumin infusion should NOT be routinely administered for hypoalbuminemia alone; instead, treatment must focus on addressing the underlying cause, with albumin reserved for specific evidence-based indications primarily in liver disease complications. 1, 2

Primary Treatment Approach for Hypoalbuminemia

• Treat the underlying cause rather than the low albumin level itself, as hypoalbuminemia reflects inflammation, malnutrition, or protein loss—not a primary albumin deficiency 2, 3
• Provide adequate nutritional support with protein intake of 1.2-1.3 g/kg body weight/day, especially in malnourished patients 2, 4
• Recognize that simply administering albumin to patients with hypoalbuminemia has not been shown to improve survival or reduce morbidity in most clinical contexts 3, 5

Evidence-Based Indications for Albumin Infusion

Liver Disease (Strong Recommendations)

Large-Volume Paracentesis

• Administer 8 g albumin per liter of ascites removed when removing >5 liters 2, 4, 6
• This prevents paracentesis-induced circulatory dysfunction and is a conditional recommendation with moderate certainty of evidence 1
• Personalize dosing based on baseline creatinine, volume removed, and history of hypotensive symptoms after prior procedures 1

Spontaneous Bacterial Peritonitis (SBP)

• Standard dosing protocol: 1.5 g/kg on day 1 and 1.0 g/kg on day 3 1
• This is a conditional recommendation with moderate certainty of evidence 4
• Critical caveat: Consider selective use for high-risk patients (serum bilirubin >4 mg/dL OR serum creatinine >1 mg/dL) rather than all SBP patients 1
• Infusion rate matters: The standard dose infused over 6 hours causes symptomatic circulatory overload in most patients; consider infusing over a longer duration or using reduced doses (0.75 g/kg day 1,0.5 g/kg day 3) 7
• Carefully assess volume status, cardiovascular status, and kidney impairment before each infusion and modify dose/frequency accordingly 1

NOT Recommended (Strong Evidence Against)

Decompensated Cirrhosis with Hypoalbuminemia Alone

• Do NOT administer albumin to hospitalized patients with decompensated cirrhosis targeting albumin >30 g/L—a large RCT (777 patients) showed no improvement in infections, kidney dysfunction, or death, with concern for increased adverse events 1

Critically Ill Patients

• Do NOT use albumin for first-line volume replacement or to increase serum albumin levels in critically ill adults (excluding thermal injuries and ARDS) 2, 4
• No benefit demonstrated for neonatal/pediatric critical care, cardiovascular surgery, or kidney replacement therapy 4

Chronic Outpatient Management

• Do NOT use weekly or biweekly albumin infusions for nonhospitalized cirrhosis patients with persistent ascites—evidence is conflicting and insufficient 1

Administration Guidelines from FDA Label

Dosing by Indication 8

Hypovolemic Shock:

• Administer 25% albumin (Plasbumin-25) intravenously
• Total dose should not exceed 2 g/kg body weight in absence of active bleeding
• Monitor hemodynamic response closely

Burns (after 24 hours):

• Target plasma albumin concentration of 2.5 ± 0.5 g/100 mL
• Target plasma oncotic pressure of 20 mm Hg
• Use 25% albumin for optimal effect

Hypoproteinemia:

• Adults: 50-75 g daily
• Children: 25 g daily
• Rate restriction: Do not exceed 2 mL/minute in hypoproteinemic patients to prevent circulatory embarrassment and pulmonary edema 8

Neonatal Hemolytic Disease:

• 1 g/kg body weight given 1 hour prior to exchange transfusion
• Caution in hypervolemic infants 8

Preparation and Administration 8

• May be administered undiluted or diluted in 0.9% NaCl or 5% dextrose
• If sodium restriction required, use only undiluted or with 5% dextrose
• Use only 16-gauge needles for 20 mL vials and larger
• Inspect for particulate matter before administration

Critical Safety Considerations

Adverse Effects to Monitor 2, 4

• Fluid overload (most common—monitor volume status carefully)
• Hypotension
• Hemodilution requiring RBC transfusion
• Anaphylaxis
• Peripheral gangrene from dilution of natural anticoagulants

Common Pitfalls to Avoid

1. Assuming hypoalbuminemia equals malnutrition: Inflammation is often the primary driver, not nutritional deficiency 2, 3
2. Using standard SBP dosing without rate adjustment: Infusing 1.5 g/kg over 6 hours causes circulatory overload in most patients—extend infusion duration 7
3. Ignoring volume status: Always assess cardiovascular status and kidney function before each infusion 1
4. Treating the number instead of the patient: Albumin level is a marker of disease severity, not a therapeutic target in most conditions 3, 5

Special Populations

Dialysis Patients 2

• Target predialysis albumin ≥4.0 g/dL (bromcresol green method)
• Focus on adequate nutrition (1.2-1.3 g/kg/day protein), adequate dialysis clearance, and treating inflammation
• Monitor normalized protein nitrogen appearance (nPNA) with target ≥0.9 g/kg/day
• Do NOT use albumin for intradialytic hypotension prevention 2

Surgical Patients 2

• Preoperative albumin <3.0 g/dL increases surgical complications
• Optimize nutrition preoperatively rather than administering albumin
• Correct nutritional deficiency when feasible before cardiac surgery