What are the indications and dosages for albumin (human albumin) administration in various medical conditions?

Albumin Dosing and Indications

Albumin should be used primarily for cirrhosis-related complications (large-volume paracentesis >5L, spontaneous bacterial peritonitis, and hepatorenal syndrome) with specific evidence-based dosing protocols, while its use in general critical care remains controversial and should be reserved as second-line therapy when crystalloids prove insufficient. 1

Strong Evidence-Based Indications

Large-Volume Paracentesis

• Administer 8 g of albumin per liter of ascites removed when drainage exceeds 5 liters 1, 2
• Use 20% or 25% albumin solution (100 mL of 20% albumin per 3 liters removed) 2
• Infuse albumin after paracentesis completion, not during the procedure 2
• For volumes <5 liters, albumin is not mandatory unless the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 2
• This dosing prevents post-paracentesis circulatory dysfunction, reducing odds by 61%, hyponatremia by 42%, and mortality by 36% 2

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5 g/kg albumin within 6 hours of SBP diagnosis, followed by 1.0 g/kg on day 3 1
• This regimen reduces kidney impairment (10% vs 33%, P=0.002) and in-hospital mortality (10% vs 29%, P=0.01) 1
• Albumin plus antibiotics is superior to antibiotics alone for this specific indication 1

Hepatorenal Syndrome (HRS-AKI)

• Initial dose: 1 g/kg before starting vasoconstrictor therapy (typically terlipressin) 1
• Maintenance: 20-40 g/day albumin during vasoconstrictor treatment 1
• Continue treatment until complete response (serum creatinine <1.5 mg/dL) or maximum 14 days 1
• The combination of terlipressin plus albumin achieves response rates of 64-76%, with complete response in 46-56% of cases 1
• Albumin's benefit extends beyond volume expansion through antioxidant and anti-inflammatory properties 1

Conditional/Second-Line Indications

Hypovolemic Shock and Burns

• For hypovolemic shock: Use 25% albumin at doses not exceeding 2 g/kg body weight in absence of active bleeding 3
• The volume expansion effect is 3-4 times the infused volume when using 25% albumin in normally hydrated patients 3
• For burns beyond 24 hours: Maintain plasma albumin at 2.5 ± 0.5 g/100 mL (plasma oncotic pressure 20 mmHg) 3
• Typical adult dose: 50-75 g daily; pediatric dose: 25 g daily 3
• Administration rate should not exceed 2 mL/minute in hypoproteinemic patients to avoid circulatory overload 3

Septic Shock (Controversial)

• Consider 20% albumin as adjunctive therapy only when large volumes of crystalloids are required 1
• The 2024 ICTMG guidelines suggest albumin should NOT be used routinely in critical care 1
• Evidence remains insufficient, with ongoing trials (1,660 patients) examining 20% albumin vs usual care fluids for 90-day mortality 1
• If used, hypoalbuminemia (serum albumin ≤25 g/L) acts as an effect moderator, suggesting greater benefit in this subgroup 4

Cardiac Surgery and ARDS

• Cardiopulmonary bypass: Adjust pump prime to achieve hematocrit 20% and plasma albumin 2.5 g/100 mL 3
• For ARDS with hypoproteinemia and fluid overload: Use 25% albumin with diuretic 3
• High-risk cardiac surgery patients are being studied in ongoing trials (590 patients) with 20% albumin for 15 hours post-ICU arrival 1

Renal Replacement Therapy

• For intradialytic hypotension: 20-25% albumin reduces hypotension better than saline when serum albumin is low 4
• Typical volume: 100 mL of 25% albumin, with extreme caution to avoid fluid overload 3
• An ongoing trial (856 patients) is examining 25% albumin (100 mL two doses) with each dialysis treatment for up to 14 days 1

Situations Where Albumin is NOT Warranted

Do not use albumin for: 1, 3

• Correction of hypoalbuminemia alone (chronic nephrosis, cirrhosis, malnutrition)
• Nutritional supplementation in protein-losing states
• Routine fluid resuscitation in general ICU patients
• Extraperitoneal infections in cirrhosis (conflicting evidence with higher pulmonary edema rates) 1

Critical Dosing Considerations

Formulation Selection

• 4-5% albumin: Isooncotic, expands plasma volume by approximately the infused volume 5
• 20-25% albumin: Hyperoncotic, expands plasma volume 3-4 times the infused volume by drawing interstitial fluid 3, 6
• The choice depends on volume status: use 5% if dehydrated, 20-25% if fluid overloaded 3

Albumin Retention in Sepsis

• Septic patients retain only 68.5% of infused albumin at 4 hours vs 79% in healthy controls (P<0.001) 6
• Volume expansion peaks at 30 minutes: 430 mL equivalent in septic patients vs 500 mL in controls after 200 mL of 20% albumin 6
• This faster transcapillary escape necessitates higher or more frequent dosing in septic patients 6

Common Pitfalls to Avoid

• Do not delay paracentesis due to coagulopathy: Routine PT/INR and platelet correction is unnecessary even with severe abnormalities 2
• Do not artificially slow paracentesis drainage: Rapid removal (2-9 L/hour) is safe and causes minimal hemodynamic changes 2
• Do not use albumin empirically for low serum albumin levels: This does not improve outcomes in chronic conditions 1, 3
• Monitor for circulatory overload: Particularly in hypoproteinemic patients receiving >2 mL/minute infusion rates 3
• Avoid in patients with cardiac contraindications: Screen with ECG before terlipressin-albumin therapy for HRS 1