What are the indications for albumin (human albumin) administration?

Indications for Albumin Administration

Albumin is strongly recommended for specific liver-related complications in cirrhosis—including large-volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome—but should NOT be used routinely for hypoalbuminemia correction, general critical illness, or nutritional purposes. 1, 2

Established Evidence-Based Indications

Cirrhosis-Related Complications (Strong Recommendations)

Large-Volume Paracentesis:

• Administer 8 g of albumin per liter of ascites removed after the procedure is completed 2
• Studies evaluating 5-10 g/L removed suggest 6-8 g/L is appropriate 2
• This prevents paracentesis-induced circulatory dysfunction 1

Spontaneous Bacterial Peritonitis (SBP):

• Give 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 2
• This dosing reduces kidney impairment and mortality 2
• The AASLD 2024 guidelines strongly support this indication 1

Hepatorenal Syndrome (HRS):

• Albumin is recommended as part of the treatment regimen 1
• Supports colloid osmotic pressure while binding excess bilirubin 3

Sepsis-Induced Hypotension in Cirrhosis:

• A 2024 RCT (n=308) showed 5% albumin versus normal saline resulted in higher 1-week survival (43.5% vs. 38.3%, p=0.03) 1
• Higher rates of shock reversal with albumin, though one study showed increased pulmonary complications 1

FDA-Approved Indications (Beyond Cirrhosis)

Hypovolemic Shock:

• 25% albumin (Plasbumin-25) is hyperoncotic and expands plasma volume 3-4 times the administered volume 3
• Total dose should not exceed 2 g/kg body weight in absence of active bleeding 3
• 5% albumin preferred for usual volume deficits; 25% may offer advantages in oncotic deficits or delayed shock treatment 3

Burn Therapy:

• Beyond 24 hours post-thermal injury, 25% albumin maintains plasma colloid osmotic pressure 3
• First 24 hours require large volumes of crystalloids 3

Cardiopulmonary Bypass:

• Used in pump priming to achieve hematocrit of 20% and plasma albumin of 2.5 g/100 mL 3

Neonatal Hemolytic Disease:

• 1 g/kg body weight given 1 hour prior to exchange transfusion to bind free bilirubin and reduce kernicterus risk 3

Adult Respiratory Distress Syndrome (ARDS):

• When hypoproteinemia with fluid overload is present, 25% albumin with diuretic may play a role 3

Situations Where Albumin is NOT Recommended

Strong Recommendations Against Use

Routine Critical Care:

• NOT recommended for first-line volume replacement in critically ill adults, neonates, or pediatric patients 4
• NOT for routine cardiovascular surgery 2, 4
• NOT for routine kidney replacement therapy 2, 4

Hypoalbuminemia Correction:

• Treatment should focus on addressing underlying cause, not correcting albumin level 4
• In chronic nephrosis, infused albumin is promptly excreted with no relief of edema 3
• NOT justified in chronic cirrhosis, malabsorption, protein-losing enteropathies, or malnutrition as protein nutrition source 3

Admitted Cirrhosis Patients:

• The 2024 ATTIRE trial (n=777) showed NO benefit in composite endpoint (infection, renal failure, death) when targeting albumin levels of 3 g/L 1
• Significantly higher rates of pulmonary edema and fluid overload with routine albumin targeting 1

Critical Safety Considerations

Fluid Overload Risk:

• Doses exceeding 87.5 g (>4×100 mL of 20% albumin) associated with worse outcomes in cirrhosis 2
• Careful monitoring required, especially in patients with rising serum creatinine 2
• Pulmonary edema is a documented complication, particularly with higher doses or rapid administration 2

Other Adverse Effects:

• Hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene from dilution of natural anticoagulants 4

Controversial/Emerging Indications (Weak Evidence)

Septic Shock (Non-Cirrhosis):

• Meta-analyses show albumin decreased mortality more than hydroxyethyl starch and saline in sepsis 1
• However, broader use as resuscitation agent in ACLF is not well defined 1

Intradialytic Hypotension:

• 25 g albumin per dialysis session improved hypotension in patients with albumin <30 g/L, but guidelines suggest against routine use 2

Acute Kidney Injury:

• May be indicated before etiological diagnosis in cirrhosis patients 5

Practical Algorithm for Decision-Making

1. Is the patient cirrhotic with specific complications?

   • YES → Use albumin for LVP (8 g/L removed), SBP (1.5 g/kg then 1.0 g/kg day 3), or HRS 1, 2
   • NO → Proceed to step 2

2. Is this hypovolemic shock, burns >24h, or neonatal hemolytic disease?

   • YES → Consider albumin per FDA indications 3
   • NO → Proceed to step 3

3. Is this routine critical care, hypoalbuminemia correction, or nutritional support?

   • YES → DO NOT use albumin; use crystalloids and address underlying cause 2, 4, 3

4. Monitor for fluid overload: Keep doses <87.5 g in cirrhosis, watch for pulmonary edema 2