What is the recommended dose of Albumin (Human Albumin) for intravenous administration?

Albumin Dosing for Intravenous Administration

The recommended dose of intravenous albumin varies by clinical indication: for spontaneous bacterial peritonitis in cirrhosis, give 1.5 g/kg within 6 hours of diagnosis followed by 1.0 g/kg on day 3; for large-volume paracentesis, give 8 g per liter of ascites removed after the procedure; for hypovolemic shock, the total dose should not exceed 2 g/kg body weight; and for most other indications, typical adult dosing ranges from 50-75 g daily. 1, 2

Cirrhosis-Specific Dosing (Strongest Evidence)

Spontaneous Bacterial Peritonitis

• Administer 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1, 3
• This regimen reduces kidney impairment (OR 0.21; 95% CI 0.11-0.42) and mortality (OR 0.34; 95% CI 0.19-0.60) 3
• The largest trial (126 patients) showed lower rates of kidney impairment (10% vs 33%; P = 0.002) and in-hospital mortality (10% vs 29%; P = 0.01) with this dosing 3

Large-Volume Paracentesis

• Give 8 g of albumin per liter of ascites removed, administered after the procedure is completed 1, 3
• Studies have evaluated 5-10 g/L removed; 6-8 g/L appears appropriate if albumin is used 3
• This indication applies primarily to paracentesis >5 L, though albumin use is reasonable (not mandatory) for volumes exceeding this threshold 3

Critical Dosing Warning for Cirrhosis

• Do not exceed 87.5 g per administration (equivalent to 4×100 mL of 20% albumin) 1
• Higher doses are associated with worse outcomes due to fluid overload, particularly pulmonary edema 3, 1
• Monitor carefully for circulatory overload, especially in patients with rising serum creatinine 1

Hypovolemic Shock and Burns

Acute Hypovolemia

• Total dose should not exceed 2 g/kg body weight in the absence of active bleeding 2
• The volume administered and speed of infusion must be adapted to individual patient response 2
• 25% albumin (hyperoncotic) expands plasma volume by 3-4 times the infused volume by withdrawing fluid from interstitial spaces 2

Burn Therapy (Beyond 24 Hours)

• Aim to maintain plasma albumin concentration at 2.5 ± 0.5 g/100 mL (equivalent to plasma oncotic pressure of 20 mm Hg) 2
• Use 25% albumin as the preferred formulation for this indication 2
• Duration of therapy depends on protein loss from burned areas and urine 2

Hypoproteinemia and Edema

General Dosing

• Usual daily dose for adults: 50-75 g; for children: 25 g 2
• Patients with severe hypoproteinemia who continue to lose albumin may require larger quantities 2
• Rate of administration should not exceed 2 mL/minute in hypoproteinemic patients to avoid circulatory embarrassment and pulmonary edema 2

Important Caveat

• Hypoproteinemic patients usually have approximately normal blood volumes, making slower infusion rates critical 2
• Unless the underlying pathology can be corrected, albumin administration is purely symptomatic or supportive 2

Concentration Selection: 5% vs 20% vs 25%

Pharmacokinetic Differences

• 20% albumin produces twice the infused volume as plasma expansion 4
• 5% albumin results in one-third of the volume quickly leaking out of plasma when patient's baseline colloid osmotic pressure exceeds the solution's osmotic pressure 4
• At 6 hours, capillary leakage is similar between concentrations (42% for 20% vs 47% for 5%) 4

Practical Selection

• Use 25% albumin for hyperoncotic needs (shock, burns, hypoproteinemia with fluid overload) 2
• Use 5% albumin when additional volume is needed or when sodium restriction is not required 2
• If sodium restriction is required, administer 25% albumin undiluted or diluted only in 5% dextrose in water 2

Special Populations and Situations

Neonatal Hemolytic Disease

• Give 1 g/kg body weight approximately 1 hour prior to exchange transfusion 2
• This dose binds free bilirubin to lessen kernicterus risk 2
• Exercise caution in hypervolemic infants 2

Cardiopulmonary Bypass

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

Hemodialysis with Intradialytic Hypotension

• 25% albumin (25 g dose) given with each dialysis session improved hypotension and ultrafiltration in patients with serum albumin <30 g/L 3
• However, the annual cost approaches $20,000 per patient, and guidelines suggest against routine use given lack of definitive benefit over alternatives 3

Administration Technique

Preparation and Infusion

• Only use 16-gauge needles or dispensing pins for vial sizes 20 mL and larger 2
• Swab stopper with antiseptic immediately before entering vial 2
• Penetrate stopper perpendicular to plane within the raised ring area 2
• May be administered undiluted or diluted in 0.9% sodium chloride or 5% dextrose in water 2

Rate Considerations

• For hypoproteinemia: maximum 2 mL/minute 2
• For shock: rate adapted to patient response 2
• Slower rates minimize risk of circulatory overload 2

When NOT to Use Albumin

The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommend against routine albumin use in: 3

• Neonatal, pediatric, and adult critical care patients
• Patients experiencing intradialytic hypotension (as routine therapy)
• Patients undergoing cardiovascular surgery
• Admitted patients with cirrhosis for treatment of hypoalbuminemia alone or extraperitoneal infections

Neonatal Populations

• Do not use albumin routinely in preterm neonates 3, 5
• Cochrane reviews found no mortality benefit and no improvement in clinically important outcomes 3, 5
• The FEAST trial in children showed excess mortality with albumin bolus strategy (RR 1.45; 95% CI 1.10-1.92) 5

Hypoalbuminemia as an Effect Moderator

Baseline serum albumin levels influence the volume effectiveness of albumin administration: 6

• In the SAFE study, the saline-to-albumin ratio was significantly higher in patients with baseline albumin ≤25 g/L compared to >25 g/L 6
• Volume effectiveness appears greater when serum albumin levels are low 6
• This suggests hypoalbuminemia acts as an effect moderator, potentially informing when to include albumin in fluid resuscitation requiring large crystalloid volumes 6