What are the indications for albumin supplementation in patients with Chronic Liver Disease (CLD)?

Indications for Albumin in Chronic Liver Disease

Albumin should be administered in patients with chronic liver disease for four well-established indications: large-volume paracentesis (>5L), spontaneous bacterial peritonitis, hepatorenal syndrome (in combination with vasoconstrictors), and sepsis-induced hypotension. 1

Established Evidence-Based Indications

Large-Volume Paracentesis

• Administer albumin when removing >5L of ascitic fluid to prevent paracentesis-induced circulatory dysfunction 1, 2
• This indication has moderate certainty of evidence and represents one of only two conditional recommendations supporting albumin use in the 2024 International Collaboration for Transfusion Medicine Guidelines 1

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5 g/kg at diagnosis and 1.0 g/kg on day 3 1, 2
• This is a strong recommendation with moderate certainty of evidence 1
• Albumin reduces mortality and prevents hepatorenal syndrome in SBP patients 1, 2

Hepatorenal Syndrome (HRS-AKI)

• Administer 1 g/kg/day for 2 consecutive days as a diagnostic challenge, followed by 20-40 g/day combined with vasoconstrictors for treatment 3
• Albumin alone is ineffective; it must be combined with vasoconstrictors 3
• Start treatment as early as possible, as higher baseline creatinine predicts treatment failure 3
• Each 1 mg/dL reduction in creatinine reduces mortality risk by 27% 3

Sepsis-Induced Hypotension

• Use 5% albumin over normal saline in cirrhotic patients with sepsis-induced hypotension 1
• A 2024 RCT (n=308) demonstrated higher 1-week survival with albumin (43.5% vs 38.3%, p=0.03) 1
• Albumin achieves higher rates of shock reversal compared to crystalloids 1

Emerging Indication: Hepatic Encephalopathy

Acute Hepatic Encephalopathy

• Consider albumin 1.5 g/kg on day 1 followed by 1.0 g/kg on day 3, combined with lactulose 2
• Alternative regimen: 1.5 g/kg/day for up to 10 days with lactulose 2
• Evidence shows 75% complete resolution with albumin-lactulose versus 53% with lactulose alone (p=0.03) 2
• Reduced mortality at day 10 (18% vs 32%, p=0.04) and improved 90-day transplant-free survival (23% vs 47%, p=0.02) 2
• This represents a conditional recommendation with low to very low certainty of evidence 1

Indications NOT Supported by Evidence

Routine Volume Replacement

• Do not use albumin as first-line volume replacement in critically ill patients with cirrhosis 1
• Balanced crystalloids (lactated Ringer's) are preferred for initial resuscitation 1, 3
• The 2024 guidelines conditionally recommend against albumin for routine volume replacement (moderate certainty of evidence) 1

Targeting Serum Albumin Levels

• Do not administer albumin to maintain specific serum albumin levels 1
• The ATTIRE trial (n=777) showed no benefit in preventing infection, renal failure, or death when targeting albumin ≥3 g/dL 1, 4
• This strategy significantly increased pulmonary edema and fluid overload 1, 4

Routine Use in Non-SBP Infections

• Evidence is insufficient to recommend albumin for infections other than SBP 1
• This remains an area requiring further study 5, 6

Critical Safety Considerations

Risk of Pulmonary Edema

• Monitor closely for volume overload, especially in patients with increased capillary permeability 1, 4, 2
• Patients with cirrhosis have higher risk due to altered vascular permeability 4, 2
• In septic shock, 20% albumin showed higher rates of pulmonary complications despite better shock reversal 1
• Immediately discontinue albumin if pulmonary edema develops 4

Monitoring During Administration

• Use transthoracic echocardiography to assess volume status and cardiac function 1, 3, 4
• Monitor dynamic changes in stroke volume, stroke volume variation, and pulse pressure variation 1, 3, 4
• Continuous monitoring of respiratory rate and oxygen saturation is essential 4

Practical Algorithm for Albumin Use

Step 1: Identify the specific indication

• Large-volume paracentesis >5L → Give albumin 1
• SBP diagnosis → Give 1.5 g/kg, then 1.0 g/kg on day 3 1, 2
• HRS-AKI → Give 1 g/kg/day × 2 days, then 20-40 g/day with vasoconstrictors 3
• Sepsis-induced hypotension → Use 5% albumin over saline 1
• Acute hepatic encephalopathy → Consider 1.5 g/kg day 1.0 g/kg day 3 with lactulose 2

Step 2: Assess contraindications

• Evaluate cardiac and pulmonary function before administration 2
• Check for signs of volume overload 1, 4

Step 3: Monitor during and after administration

• Perform echocardiography to guide fluid management 1, 3, 4
• Watch for respiratory distress or declining oxygen saturation 4

Step 4: If albumin unavailable

• Use balanced crystalloids (lactated Ringer's) as alternative 3
• Avoid normal saline due to higher mortality in critically ill patients 1, 3

Key Pitfalls to Avoid

• Do not use albumin broadly as a resuscitation agent outside the four established indications 1
• Do not attempt to "correct" low albumin levels in hospitalized cirrhotic patients 1
• Do not give albumin without vasoconstrictors in hepatorenal syndrome 3
• Do not ignore early signs of volume overload, as cirrhotic patients are particularly vulnerable 1, 4, 2