How to correct hypoalbuminemia with intravenous (IV) albumin?

How to Correct Hypoalbuminemia with Intravenous Albumin

In most clinical situations, you should NOT routinely administer IV albumin to correct hypoalbuminemia—instead, focus on treating the underlying cause and providing adequate nutritional support. 1

General Principles: When NOT to Use IV Albumin

The fundamental approach to hypoalbuminemia is addressing the root cause rather than the low albumin number itself. 1

IV albumin is NOT recommended for:

• First-line volume replacement in critically ill patients (excluding specific liver disease scenarios) 2, 1
• Simply raising serum albumin levels in hypoalbuminemic patients 1
• Nutritional support or protein supplementation 3, 4
• Conjunction with diuretics for fluid removal in most patients 1
• Infections other than spontaneous bacterial peritonitis 2

The evidence is clear: randomized controlled trials show that while IV albumin raises serum albumin levels, it does not improve morbidity or mortality in most hypoalbuminemic patients receiving nutritional support. 4

Specific Clinical Scenarios Where IV Albumin IS Indicated

Cirrhosis-Related Complications (Strongest Evidence)

Large-Volume Paracentesis (>5 Liters)

• Administer 8 grams of albumin per liter of ascitic fluid removed 2, 5
• This prevents post-paracentesis circulatory dysfunction 2
• In patients with acute-on-chronic liver failure, use 6-8 g/L regardless of volume removed 2

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5 g/kg body weight on day 1 and 1.0 g/kg on day 3 2, 5
• This reduces acute kidney injury (10% vs 33%) and mortality (10% vs 29%) compared to antibiotics alone 2
• Patients with serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL benefit most 2
• Do NOT use albumin for other infections in cirrhosis—it increases pulmonary edema without benefit 2

Hepatorenal Syndrome

• Combine albumin with vasoconstrictors for hepatorenal syndrome-acute kidney injury 5

Acute Kidney Injury in Cirrhosis with Ascites

For Stage 2-3 AKI (not Stage 1):

• Withdraw diuretics immediately 2
• Administer 1 g/kg body weight albumin daily for 2 consecutive days 2
• Maximum dose should not exceed 100 g per day 2
• This allows differential diagnosis and treats pre-renal AKI 2

For Stage 1 AKI:

• Do NOT give albumin initially 2
• First withdraw nephrotoxic drugs, reduce/stop diuretics, and treat infections 2
• Only escalate to albumin if progression occurs 2

Administration Guidelines

Dosing by Indication

From FDA labeling: 6

• Hypovolemic shock: Individualize volume and rate; total dose should not exceed 2 g/kg body weight
• Burns (after 24 hours): Target plasma albumin 2.5 ± 0.5 g/dL (equivalent to plasma oncotic pressure of 20 mm Hg)
• Hypoproteinemia: Adults 50-75 g daily, children 25 g daily (symptomatic treatment only)

Infusion Rate

• In hypoproteinemic patients with normal blood volumes: do not exceed 2 mL/minute 6
• Faster rates risk circulatory overload and pulmonary edema 6

Preparation

• Use only 16-gauge needles or larger for vials ≥20 mL 6
• Can be given undiluted or diluted in 0.9% saline or 5% dextrose 6
• If sodium restriction needed, dilute only in sodium-free solutions like 5% dextrose 6

Critical Safety Considerations

Major Adverse Effects to Monitor

Albumin carries significant risks: 7

• Fluid overload and pulmonary edema (most common, especially in cardiac/pulmonary compromise) 7
• Hypotension and tachycardia (paradoxically, despite volume expansion) 7
• Hemodilution requiring RBC transfusion 7
• Anaphylactic/allergic reactions (rash, pruritus, rigors, fever) 7

Patients with cirrhosis face higher risk due to increased capillary permeability and impaired lymphatic drainage. 7

Cost Considerations

• Albumin costs approximately $130 per 25 grams 1
• This expense must be weighed against lack of mortality benefit in most situations 1

Common Pitfalls to Avoid

Do not assume hypoalbuminemia equals malnutrition. 1 In most hospitalized patients, low albumin reflects:

• Systemic inflammation (inflammatory cytokines suppress hepatic albumin synthesis) 1
• Increased capillary permeability with transcapillary albumin loss 1
• Hemodilution from fluid overload 1

Measure C-reactive protein or other inflammatory markers to distinguish inflammation-driven hypoalbuminemia from true nutritional deficiency. 1

The Albumin-Furosemide Combination: Not Recommended

Do NOT routinely combine albumin with furosemide for diuresis. 8

The evidence shows:

• No improvement in mortality, ventilator-free days, or clinical outcomes 8
• Significant risks of fluid overload, pulmonary edema, and hypotension 8
• High cost without proven benefit 8

The only exception is large-volume paracentesis in cirrhosis, where albumin (8 g/L removed) may be given with furosemide to prevent post-paracentesis circulatory dysfunction. 8

What to Do Instead of Giving Albumin

Primary Management Strategy

1. Identify and treat the underlying cause (inflammation, infection, protein loss, liver disease) 1
2. Provide adequate nutrition: 1.2-1.3 g/kg/day protein intake 1
3. Correct fluid overload (hemodilution artificially lowers albumin) 1
4. Minimize protein losses (treat proteinuria, reduce dialysate losses) 1
5. Control inflammation when present 1

Target Albumin Levels

• In dialysis patients: aim for ≥4.0 g/dL (bromcresol green method) 1
• In surgical patients: recognize that <3.0 g/dL increases surgical risk, but optimize nutrition preoperatively rather than giving albumin 1

Special Populations

Dialysis Patients

Never use albumin as first-line treatment. 9 Instead:

• Ensure adequate dialysis clearance (Kt/V) 1
• Provide 1.2-1.3 g/kg/day protein intake 1
• Treat inflammation and catabolic illness 1
• Monitor normalized protein nitrogen appearance (target ≥0.9 g/kg/day) 1

Consider albumin only for volume overload with reduced effective arterial volume to mobilize edema fluid for ultrafiltration. 9

Neonatal Hemolytic Disease

• Give 1 g/kg body weight approximately 1 hour before exchange transfusion to bind free bilirubin 6
• Use caution in hypervolemic infants 6