What are the potential complications of using Albumin (human albumin)?

Complications of Albumin Administration

The primary complications of intravenous albumin are fluid overload and pulmonary edema, particularly in patients with cirrhosis or compromised cardiopulmonary function, with additional risks including hypotension/tachycardia, allergic reactions, and hemodilution. 1, 2

Major Complications

Fluid Overload and Pulmonary Edema

• This is the most significant and common complication, especially in patients with cirrhosis who have increased capillary permeability and compromised lymphatic drainage capacity. 1, 2
• The ATTIRE trial demonstrated that targeting elevated albumin levels in hospitalized patients with decompensated cirrhosis resulted in significantly higher rates of pulmonary edema and fluid overload compared to standard care. 1
• Risk is particularly elevated when albumin is used with terlipressin, as the combination can increase cardiac afterload and precipitate respiratory failure (14% vs 5% in placebo groups). 1
• Patients with ACLF grade 3 (≥3 organ failures) are at highest risk for respiratory complications. 1

Cardiovascular Complications

• Hypotension and tachycardia can paradoxically occur despite albumin being administered to treat hypovolemia. 1, 2
• These adverse events are generally dose-dependent, though they can develop even at lower doses. 1

Allergic and Infusion Reactions

• Anaphylactic/allergic reactions including rash, pruritus, rigors, and pyrexia can occur. 1, 2
• These reactions require immediate cessation of infusion and supportive management. 3

Hemodilution

• Dilutional effects may necessitate red blood cell transfusion to correct anemia. 2
• This is particularly relevant in critically ill patients requiring multiple albumin infusions. 2

High-Risk Clinical Scenarios

Cirrhosis-Specific Risks

• Patients with cirrhosis receiving albumin for extraperitoneal infections (non-SBP infections) show higher rates of pulmonary edema without mortality benefit. 1
• Three RCTs and meta-analysis confirmed albumin does not reduce AKI or mortality risk in cirrhotic patients with infections other than SBP, and was associated with more pulmonary edema. 1
• Circulatory overload is more common in cirrhotic patients receiving albumin versus crystalloid. 2

Sepsis and Critical Illness

• In septic shock, 20% albumin showed higher rates of shock reversal but increased pulmonary complications compared to Plasma-Lyte. 1
• Albumin may not be effective for first-line volume replacement in critical care patients and can lead to adverse effects. 2

Contraindications and Cautions

• Avoid albumin in patients with SpO2 <90% when used with terlipressin for hepatorenal syndrome. 1
• Exercise extreme caution in patients with ACLF grade 3 due to increased respiratory failure risk. 1
• Do not use for routine hypoalbuminemia correction, as this increases complications without proven benefit. 1, 4

Prevention and Monitoring Strategies

Judicious Dosing

• Limit albumin to evidence-based indications: large-volume paracentesis (>5L), spontaneous bacterial peritonitis, and hepatorenal syndrome. 1, 3
• For HRS-AKI treatment: use 20-40 g/day with vasoconstrictors, not albumin alone. 5
• For SBP: administer 1.5 g/kg on day 1 and 1 g/kg on day 3. 1

Clinical Monitoring

• Monitor continuously for signs of fluid overload: respiratory distress, pulmonary rales, peripheral edema, and oxygen saturation. 2, 3
• Perform transthoracic echocardiography to assess cardiac function and volume status before and during therapy. 5, 3
• Assess vital signs including pulse oximetry every 2-4 hours during treatment. 1
• Monitor dynamic hemodynamic parameters (stroke volume variation, pulse pressure variation) during fluid resuscitation. 1, 5

Immediate Management of Complications

• Stop albumin infusion immediately if pulmonary edema develops. 3
• Provide supplemental oxygen and elevate head of bed. 3
• Consider vasopressors (norepinephrine 0.01-0.5 μg/kg/min) if hypotension persists. 3
• Avoid additional albumin administration in patients with increased capillary permeability. 3

Key Clinical Pitfalls

• Do not target specific serum albumin levels in hospitalized cirrhotic patients, as this practice increases pulmonary complications without benefit. 1
• Avoid albumin for non-SBP infections in cirrhosis, as it provides no benefit and increases pulmonary edema risk. 1
• Do not use albumin as first-line volume resuscitation in general critical care (balanced crystalloids are preferred). 1, 2
• Recognize that adverse events are dose-dependent, so use the minimum effective dose for approved indications. 1