When should intravenous (IV) albumin be administered?

When to Give IV Albumin

IV albumin should be administered primarily in two evidence-based scenarios in cirrhosis: large-volume paracentesis (>5 liters) and spontaneous bacterial peritonitis, with limited support for routine use in most other clinical situations. 1

Evidence-Based Indications (Strong Recommendations)

Cirrhosis-Related Indications

Large-Volume Paracentesis (>5 liters)

• Administer 8g albumin per liter of ascites removed using 20% or 25% albumin solution 2, 3, 4
• Infuse after paracentesis completion to prevent post-paracentesis circulatory dysfunction, which reduces this complication by 61% 4
• This prevents renal impairment and circulatory dysfunction by expanding effective arterial blood volume 4

Spontaneous Bacterial Peritonitis

• Give 1.5g/kg albumin within 6 hours of diagnosis, followed by 1.0g/kg on day 3 2, 3, 4
• This regimen reduces renal impairment by 54% and mortality by 34% at 3 months 4
• Prioritize for patients with creatinine >1 mg/dL or bilirubin >4 mg/dL 4
• The American Association for the Study of Liver Diseases strongly supports this indication 2

Other Accepted Uses (Per FDA Label)

Emergency Hypovolemic Shock

• Plasbumin-25 (25% albumin) expands plasma volume 3-4 times the infused volume by withdrawing interstitial fluid 5
• Total dose should not exceed 2g/kg body weight in absence of active bleeding 5
• Must be supplemented with crystalloids if patient is dehydrated 5

Burn Therapy (After 24 Hours)

• Use after initial 24-hour crystalloid resuscitation to maintain plasma colloid osmotic pressure 5
• Not recommended during first 24 hours when crystalloids are preferred 5

Neonatal Hemolytic Disease

• Give 1g/kg body weight approximately 1 hour prior to exchange transfusion to bind free bilirubin 5

Where Albumin is NOT Recommended

Critical Care Settings (Strong Evidence Against)

General Volume Resuscitation

• Do NOT use albumin for first-line volume replacement in critically ill adults, pediatric, or neonatal patients 1, 3
• This carries moderate certainty of evidence from the International Collaboration for Transfusion Medicine Guidelines 1
• Crystalloids are equally effective and significantly less expensive (albumin costs ~$130/25g) 1, 2

Hypoalbuminemia Alone

• Do NOT give albumin simply to correct low serum albumin levels 1, 2
• Serum albumin concentration does not reflect albumin function in liver disease 2
• In chronic nephrosis, infused albumin is promptly excreted with no clinical benefit 5

Cardiovascular Surgery

• Routine use is NOT recommended 3
• The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommend against this 3

Chronic Conditions

• Do NOT use for protein nutrition in chronic cirrhosis, malabsorption, protein-losing enteropathies, or malnutrition 5
• Not justified as nutritional supplementation 6

Cirrhosis-Specific Situations Where Evidence is Insufficient

Hepatorenal Syndrome

• The International Collaboration for Transfusion Medicine Guidelines refrain from recommending albumin due to insufficient clinical trial evidence 1
• Prior guidelines recommended it with terlipressin, but this was based on expert opinion rather than comparative trials 1
• Requires further study before definitive recommendation 1

Modest-Volume Paracentesis (<5 liters)

• Not recommended; reserve for large-volume procedures only 4

Treatment of Hypoalbuminemia in Admitted Cirrhosis Patients

• Explicitly NOT recommended 3

Intradialytic Hypotension

• Guidelines recommend against routine use despite some physiologic benefits 3

Clinical Algorithm for Decision-Making

Step 1: Identify the Clinical Scenario

• Cirrhosis with large-volume paracentesis planned? → Proceed to albumin dosing
• Cirrhosis with confirmed SBP? → Proceed to albumin dosing
• Hypovolemic shock with active bleeding? → Consider albumin with blood products
• Burns >24 hours post-injury? → Consider albumin for oncotic support
• Any other scenario? → Albumin likely NOT indicated; use crystalloids

Step 2: Dose Appropriately

• Large-volume paracentesis: 8g per liter removed (20-25% solution) 2, 3
• SBP: 1.5g/kg within 6 hours, then 1.0g/kg on day 3 2, 3, 4
• Hypovolemic shock: Up to 2g/kg maximum 5

Step 3: Monitor for Complications

• Fluid overload: Particularly with doses >87.5g in cirrhosis patients 3
• Rapid blood pressure rise: May unmask previously non-bleeding vessels 5
• Hemodilution: May require RBC transfusion 2
• Rare complications: Anaphylaxis, peripheral gangrene from anticoagulant dilution 2

Important Caveats and Pitfalls

Avoid Fluid Overload

• Plasbumin-25 is hyperoncotic and must be given with crystalloids if patient is dehydrated 5
• Doses exceeding 87.5g may worsen outcomes in cirrhosis due to volume overload 3
• Monitor carefully for circulatory overload, especially in patients who cannot tolerate substantial fluid volumes 5

Timing Matters

• For SBP, albumin must be given within 6 hours of diagnosis for maximum benefit 3
• For paracentesis, infuse after procedure completion 3

Cost-Effectiveness Considerations

• Albumin is significantly more expensive than crystalloids 1, 2
• Use only when evidence supports superiority over alternatives 1

Ongoing Research Areas

• Long-term outpatient albumin for refractory ascites is investigational 2
• Role in septic shock requiring large crystalloid volumes mentioned by Surviving Sepsis Campaign but with limited evidence 1
• Use in acute kidney injury, extraperitoneal infections, and hyponatremia in cirrhosis remains controversial 1, 7, 8