When to administer albumin (human albumin) to patients?

When to Administer Albumin

Albumin should be administered in patients with cirrhosis undergoing large-volume paracentesis (>5L), those with spontaneous bacterial peritonitis (especially with bilirubin >4 mg/dL or baseline AKI), and patients with hepatorenal syndrome in combination with vasoconstrictors. 1

Evidence-Based Indications for Albumin Administration

Strong Indications in Cirrhosis (High-Quality Evidence)

Large-Volume Paracentesis (>5L)

• Administer albumin at 6-8 g per liter of ascites removed 1
• In patients with acute-on-chronic liver failure (ACLF), give 6-8 g/L regardless of volume removed 1
• Without albumin, 21% of patients develop AKI after daily 5-L paracenteses; zero patients developed AKI when albumin was given 1
• This prevents post-paracentesis circulatory dysfunction and reduces activation of the renin-angiotensin-aldosterone system 1

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5 g/kg on day 1 and 1.0 g/kg on day 3, in addition to antibiotics 1
• Reduces AKI from 33% to 10% and mortality from 29% to 10% 1
• Patients most likely to benefit: those with serum bilirubin >4 mg/dL and/or baseline AKI (creatinine >1.0 mg/dL and BUN >30 mg/dL) 1
• Even lower doses (10 g/day for 3 days) showed benefit, reducing renal dysfunction from 20% to 7% and mortality from 40% to 27% 1
• Albumin is superior to hydroxyethyl starch for improving systemic circulatory hemodynamics 1

Hepatorenal Syndrome

• Administer 20-40 g/day during terlipressin treatment 1
• Give 1 g/kg before initiating vasoconstrictor treatment 1
• The combination of albumin plus vasoconstrictors is more effective than vasoconstrictors alone, though the specific albumin effect remains empirical 1

Conditional Indications (Moderate Evidence)

Hypovolemic Shock (Emergency Treatment)

• Use 25% albumin (hyperoncotic) when oncotic deficits exist or in long-standing shock where treatment has been delayed 2
• Expands plasma volume by 3-4 times the volume administered by withdrawing fluid from interstitial spaces 2
• Total dose should not exceed 2 g/kg body weight in absence of active bleeding 2
• Critical caveat: If patient is dehydrated, additional crystalloids must be given, or use 5% albumin instead 2

Burn Therapy

• After the first 24 hours post-burn in patients with >30% total body surface area burns 2
• Dose: 1-2 g/kg/day to maintain albumin levels >30 g/L 3
• During first 24 hours, use large volumes of crystalloids instead 2

Cardiopulmonary Bypass

• Use albumin and crystalloid in pump prime to achieve hematocrit of 20% and plasma albumin concentration of 2.5 g/100 mL 2

Neonatal Hemolytic Disease

• Give 1 g/kg body weight approximately 1 hour prior to exchange transfusion to bind free bilirubin 2
• Caution: Must be observed in hypervolemic infants 2

Where Albumin Should NOT Be Used

Critical Care Patients Without Specific Indications

• Albumin is NOT suggested for first-line volume replacement or to increase serum albumin levels in general critically ill adults 1
• Do not use for routine treatment of hypoalbuminemia 1

Infections Other Than SBP

• Three RCTs and meta-analysis showed albumin does NOT reduce AKI or mortality in cirrhosis patients with non-SBP infections 1
• Associated with MORE pulmonary edema 1

Chronic Conditions

• NOT warranted in chronic nephrosis (promptly excreted by kidneys) 2
• NOT justified in hypoproteinemic states from chronic cirrhosis, malabsorption, protein-losing enteropathies, pancreatic insufficiency, or undernutrition as protein nutrition 2

Intradialytic Hypotension

• Guidelines suggest albumin should NOT be used routinely 1
• Despite frequent use, minimal data support routine administration during kidney replacement therapy 4

Cardiovascular Surgery

• Albumin should NOT be used routinely 1

Critical Safety Considerations

Fluid Overload Risk

• Doses exceeding 87.5 g (>4×100 mL of 20% albumin) potentially associated with worse outcomes due to fluid overload 3
• Hyperoncotic albumin (25%) requires careful monitoring in presence of dehydration 2
• Pulmonary edema reported as adverse event, particularly with rapid administration 1, 3

Infusion Rate Guidelines

• Hypovolemic patients can tolerate faster rates 3
• Euvolemic patients should be limited to 2 mL/min (≈120 mL/hour for 25% albumin) 3
• Never use serum albumin levels alone to guide infusion rate—volume status is the critical determinant 3

Monitoring Requirements

• Watch for severed blood vessels that may bleed when blood pressure rises rapidly after albumin administration 2
• Monitor continuously for fluid overload, especially when total doses exceed 87.5 g 3
• In hemorrhage, supplement albumin with whole blood transfusion to treat relative anemia from hemodilution 2

Common Pitfalls to Avoid

• Do not assume albumin is needed just because serum albumin is low—hypoalbuminemia alone is not an indication 1, 2
• Do not use albumin for nutritional purposes in chronic protein deficiency states 2
• Do not extrapolate safety data from general critical care to traumatic brain injury patients (albumin associated with higher mortality in TBI) 5
• Do not mix albumin with protein hydrolysates, amino acid solutions, or alcohol-containing solutions 2