How is low albumin treated?

Treatment of Low Albumin

The primary treatment of hypoalbuminemia is to identify and treat the underlying cause—not to simply administer albumin—while providing adequate nutritional support, controlling inflammation, and addressing protein losses. 1

Understanding Hypoalbuminemia

Low albumin is a powerful predictor of mortality and morbidity across multiple disease states, with each 1.0 g/dL decrease in serum albumin increasing mortality odds by 137% and morbidity by 89%. 1, 2 However, hypoalbuminemia is typically a marker of underlying disease severity rather than a primary problem requiring direct correction. 3

Key Pathophysiologic Mechanisms

• Inflammation directly downregulates hepatic albumin synthesis through inflammatory cytokines, even when protein and caloric intake are adequate. 1, 2, 3
• Malnutrition reduces albumin synthesis when dietary protein and energy intake are insufficient. 3
• Protein losses through kidneys (proteinuria), gastrointestinal tract, or dialysate deplete albumin stores. 1, 2
• Hemodilution from fluid overload artificially lowers measured serum albumin concentration. 1

Primary Treatment Strategy

1. Treat the Underlying Cause

This is the most critical intervention and takes priority over albumin infusion. 1

• Control active inflammation when present, as inflammation is often a more powerful predictor of poor outcomes than low albumin itself. 1
• Measure C-reactive protein or other inflammatory markers to distinguish inflammation-driven hypoalbuminemia from pure malnutrition. 1
• Correct fluid overload to eliminate hemodilution effects on albumin concentration. 1
• Minimize external protein losses by treating proteinuria or reducing dialysate losses in peritoneal dialysis patients. 1

2. Provide Adequate Nutritional Support

• Ensure protein intake of 1.2-1.3 g/kg body weight/day in clinically stable patients with chronic conditions. 4, 1
• Monitor nutrition frequently with a renal dietitian in patients with kidney disease. 4
• Target normalized protein nitrogen appearance (nPNA) ≥0.9 g/kg/day in peritoneal dialysis patients. 4

3. Optimize Dialysis Adequacy (for Dialysis Patients)

• Maintain adequate Kt/Vurea and creatinine clearance at or above recommended levels. 4
• Target predialysis or stabilized serum albumin ≥4.0 g/dL (using bromcresol green method) as the outcome goal. 1

4. Monitor Regularly

• Measure serum albumin at least every 4 months in dialysis patients. 4
• A stable or rising albumin level is the goal, as declining albumin (even 0.1 g/dL/month) indicates increased risk. 4

When Albumin Infusion IS Indicated

Albumin infusion should be reserved for specific, evidence-based clinical scenarios—not for treating hypoalbuminemia itself. 1

Strong Indications (High-Quality Evidence)

• Large-volume paracentesis (>5L) in cirrhotic patients: Administer 8 grams of albumin per liter of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction. 1, 5
• Spontaneous bacterial peritonitis: Give 1.5 g/kg body weight on day 1 and 1.0 g/kg on day 3, which reduces acute kidney injury and mortality. 1, 5
• Hepatorenal syndrome (Type 1): Administer 1 g/kg body weight albumin daily for 2 consecutive days after withdrawing diuretics. 1, 5

Weak or Conditional Indications

• Septic shock: May be considered as second-line adjunctive therapy to crystalloids for fluid resuscitation. 6
• Therapeutic plasmapheresis: For fluid replacement when large volumes of plasma are exchanged. 6, 5

When Albumin Infusion Is NOT Recommended

The following scenarios have clear evidence against albumin administration: 1

• Simply to increase serum albumin levels in any patient population. 1, 6
• First-line volume replacement in critically ill patients (excluding specific liver disease scenarios). 1
• In conjunction with diuretics for removal of extravascular fluid. 1
• For preterm neonates with respiratory distress and low albumin. 1
• For patients undergoing kidney replacement therapy to prevent or treat intradialytic hypotension. 1
• For pediatric patients undergoing cardiovascular surgery. 1
• For nutritional purposes in any clinical context. 6

Common Pitfalls to Avoid

• Assuming hypoalbuminemia equals malnutrition: Inflammation is often the primary driver, not nutritional deficiency. 1, 2, 3
• Failing to recognize albumin as a negative acute-phase reactant: Albumin decreases during inflammation regardless of nutritional status. 2, 3
• Relying on albumin infusion to correct the underlying problem: This addresses the symptom, not the cause, and has not been shown to improve survival or reduce morbidity when used solely to raise albumin levels. 3
• Ignoring non-nutritional factors: Age, comorbidities, peritoneal transport characteristics, and external protein losses all affect serum albumin independent of nutrition. 4

Risks of Albumin Infusion

• Expensive: Approximately $130 per 25g dose. 1
• Potential adverse effects: Fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, allergic reactions, and peripheral gangrene. 1, 7
• Volume overload: Particularly problematic in patients with cardiac or renal dysfunction. 7

Special Populations

Surgical Patients

• Preoperative albumin <3.0 g/dL is associated with increased risk of surgical complications, including surgical site infections and poor wound healing. 1
• Preoperative nutritional optimization is recommended when feasible before cardiac surgery (Class IIa, Level C-LD). 1

Cirrhosis Patients

• In hospitalized patients with decompensated cirrhosis, hyperoncotic albumin targeting levels >30 g/L showed no improvement in outcomes (infections, kidney dysfunction, or death) compared to no albumin. 1