What are the indications for intravenous (IV) albumin?

Indications for Intravenous Albumin

Based on the most recent 2024 international guidelines, IV albumin has only two evidence-supported indications: large-volume paracentesis (>5L) in cirrhotic patients and spontaneous bacterial peritonitis in cirrhosis—all other common uses lack evidence for improving patient outcomes and are not recommended. 1

Evidence-Based Indications (Where Albumin IS Recommended)

Cirrhosis Complications (Only Two Scenarios)

Large-Volume Paracentesis (>5L):

• Albumin is conditionally recommended to prevent paracentesis-induced circulatory dysfunction when removing more than 5 liters of ascitic fluid 1
• This indication has very low certainty of evidence but represents one of only two scenarios where guidelines support albumin use 1
• Dosing per FDA labeling: administered intravenously at appropriate volumes based on fluid removed 2

Spontaneous Bacterial Peritonitis:

• Albumin is conditionally recommended in cirrhotic patients with SBP 1
• This is the second of only two indications with guideline support 1
• Evidence certainty is very low, but clinical practice supports this use 3, 4

Additional Accepted Uses (From FDA Labeling)

• Hypovolemic shock: volume and infusion speed adapted to individual response 2
• Burns: maintain plasma albumin ~2.5 g/dL after 24 hours post-injury 2
• Hypoproteinemia with edema: 50-75g daily for adults, 25g for children, but considered purely symptomatic 2

Where Albumin Is NOT Recommended (Despite Common Use)

Critical Care Settings

General ICU Patients:

• Albumin is NOT recommended for first-line volume replacement in critically ill adults (excluding thermal injuries and ARDS) 1
• Do not use to increase serum albumin levels—this is a moderate certainty recommendation 1
• Crystalloids remain the appropriate first-line choice 3

Thermal Injuries and ARDS:

• Albumin is NOT recommended for volume replacement or to increase serum albumin levels 1
• Very low certainty of evidence 1

Fluid Removal:

• Albumin with diuretics is NOT recommended for removal of extravascular fluid in critically ill patients 1
• Very low certainty of evidence 1

Pediatric and Neonatal Populations

Preterm Neonates:

• NOT recommended for respiratory distress in neonates ≤36 weeks with low albumin 1
• NOT recommended for volume replacement in neonates ≤32 weeks or ≤1,500g 1
• Both have very low certainty of evidence 1

Pediatric Cardiovascular Surgery:

• NOT recommended for priming bypass circuits or volume replacement 1
• Very low certainty of evidence 1

Kidney Replacement Therapy

Dialysis-Related Issues:

• Albumin is NOT recommended for prevention or treatment of intradialytic hypotension 1, 5
• NOT recommended for improving ultrafiltration 1, 5
• Very low certainty of evidence but clear recommendation against use 1
• Cost is prohibitive (~$20,000 per patient annually) without proven benefit 5

Alternative approaches for intradialytic hypotension:

• Higher dialysate calcium concentration 5
• Lower dialysate temperature 5
• Individualized ultrafiltration rates 5
• Oral vasopressors like midodrine 5

Cardiovascular Surgery

• NOT recommended for adult cardiovascular surgery (insufficient evidence in guidelines) 1

Critical Clinical Pitfalls

The Hypoalbuminemia Trap:

• Low serum albumin is a marker of illness severity, not a treatment target 1
• Do not administer albumin simply to "correct" a low albumin level—this does not improve outcomes 1, 3
• Hypoalbuminemia reflects inflammatory cytokine suppression and transcapillary loss, not deficiency 1

Cost and Resource Considerations:

• Albumin costs approximately $130 per 25g (warehouse acquisition cost) 1
• This is substantially more expensive than crystalloids without proven superiority in most settings 1
• Of 14 guideline recommendations, 12 recommend AGAINST albumin use in common clinical scenarios 1

Potential Adverse Effects:

• Fluid overload and pulmonary edema (especially if infused >2 mL/min in hypoproteinemic patients) 1, 2
• Hypotension 1
• Hemodilution requiring RBC transfusion 1
• Anaphylaxis 1
• Peripheral gangrene from dilution of natural anticoagulants 1

Administration Guidelines (When Indicated)

Rate of Administration:

• In hypoproteinemic patients with normal blood volumes: do not exceed 2 mL/minute to prevent circulatory embarrassment and pulmonary edema 2
• In hypovolemic shock: adapt rate to individual patient response 2

Preparation:

• May be administered undiluted or diluted in 0.9% NaCl or 5% dextrose 2
• If sodium restriction required: use undiluted or dilute only in sodium-free solutions like 5% dextrose 2
• Use only 16-gauge needles for vials ≥20 mL 2

Summary of Evidence Quality

The 2024 International Collaboration for Transfusion Medicine Guidelines reviewed extensive evidence and found 1:

• 2 recommendations with moderate certainty of evidence
• 5 recommendations with low certainty of evidence
• 7 recommendations with very low certainty of evidence
• Only 2 of 14 recommendations conditionally support albumin use (both in cirrhosis)
• 12 of 14 recommendations advise against albumin in settings where it is commonly used

The overarching message: albumin is dramatically overused in clinical practice, with evidence supporting its use in only highly specific cirrhosis-related scenarios. 1, 3