What is the recommended dose of albumin (human albumin) for volume expansion in adults?

Albumin Dosing for Volume Expansion in Adults

For general volume expansion in adults, albumin is NOT recommended as first-line therapy; isotonic crystalloids should be used instead, with albumin reserved for specific clinical scenarios where evidence supports its use. 1

General Principles

• Crystalloids are preferred over albumin for initial volume expansion in most clinical situations, including patients at risk for or with acute kidney injury, due to similar efficacy, lower cost, and fewer potential adverse effects 1
• Albumin should be reserved for specific evidence-based indications rather than routine volume expansion 1

Specific Clinical Scenarios with Recommended Albumin Doses

Cirrhosis-Related Indications

Large-Volume Paracentesis (>5L)

• Dose: 8 g of albumin per liter of ascites removed 2
• Use 20% or 25% albumin solution to minimize fluid volume 3, 2
• This prevents post-paracentesis circulatory dysfunction, renal impairment, and hepatorenal syndrome 2
• Albumin replacement is generally not required for small-volume paracentesis (<5L) 2

Spontaneous Bacterial Peritonitis

• Dose: 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 2
• Use 25% albumin to minimize volume administered 3
• Maximum daily dose should not exceed 100 g 4
• This regimen reduces renal dysfunction risk by 72% and mortality by 47% 2

Hepatorenal Syndrome (HRS-AKI)

• Dose: 1 g/kg/day for 2 consecutive days (up to maximum 100 g/day) 4, 1
• Used for diagnostic purposes (lack of improvement after this regimen plus diuretic withdrawal confirms HRS-AKI) 1
• Continue albumin with vasoconstrictors (terlipressin or norepinephrine) based on volume status 1

Severe Burns

For burns with TBSA >30%

• Dose: 1-2 g/kg/day to maintain serum albumin levels >30 g/L 4
• Administer after the first 6 hours of management 4
• Use 5% albumin solution 4
• This reduces crystalloid volumes, decreases organ failure incidence, and may reduce mortality 4

Pediatric burns (TBSA >15%)

• Administer 5% albumin early (8-12 hours post-burn) rather than late (>12 hours) 4
• Specific dosing follows institutional protocols (Galveston or Cincinnati) 4

Albumin Concentration Selection

25% vs 5% Albumin

• 25% albumin is preferred when fluid restriction is important (cirrhosis, fluid overload risk) 3
• One 100 mL infusion of 25% albumin (25g) increases serum albumin by approximately 0.2-0.3 g/dL 3
• 25% albumin delivers the same albumin mass in one-fifth the volume compared to 5% solutions 3
• 25% albumin is more cost-effective per gram of albumin delivered 3

Volume Expansion Effects

• 20% albumin produces volume expansion approximately twice the infused volume 5
• 5% albumin produces volume expansion closer to the infused volume, with one-third quickly leaking out of plasma 5
• When equivalent albumin masses are given, 20% albumin has a dehydrating effect compared to 5% 5

Clinical Scenarios Where Albumin Should NOT Be Used

• Traumatic brain injury: Albumin is associated with harm and should be avoided 1
• Pediatric severe infections: Evidence suggests potential harm as first-line fluid 3
• Uncomplicated ascites in cirrhosis: No benefit demonstrated 1
• Septic shock as first-line therapy: Crystalloids are preferred; albumin shows no definitive mortality benefit 1
• Hemorrhagic shock: No published evidence of benefit; use balanced crystalloids instead 1

Important Caveats

• In septic patients, albumin retention is reduced compared to healthy controls (68.5% vs 79% at 4 hours), indicating faster capillary leak 6
• Albumin administration has been associated with pulmonary edema in some critically ill patients 1
• The annual cost of albumin for maintenance hemodialysis is approximately $20,000 per patient in the United States, warranting judicious use 3
• Hydroxyethyl starches are contraindicated in severe burns per European regulatory agencies 4