How is hypoalbuminemia corrected?

Hypoalbuminemia Correction

Primary Treatment Strategy

The correction of hypoalbuminemia should focus on treating the underlying cause rather than routinely administering albumin to normalize serum levels. 1, 2

The fundamental approach involves:

• Identify and treat the root cause (inflammation, malnutrition, protein loss, liver disease, kidney disease) rather than simply correcting the number 1
• Provide adequate nutritional support with protein intake of 1.2-1.3 g/kg body weight/day and 30-35 kcal/kg/day in malnourished patients 1
• Address inflammation aggressively, as inflammatory cytokines directly suppress hepatic albumin synthesis even with adequate nutrition 1
• Correct fluid overload, as hemodilution from excess fluid decreases serum albumin concentration 1

When Albumin Infusion IS Indicated

Albumin administration is appropriate only in specific clinical scenarios:

Liver Disease with Complications

• Large-volume paracentesis (>5L): Administer 8 grams of albumin per liter of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction 1, 2, 3
• Spontaneous bacterial peritonitis: Give 1.5 g/kg body weight on day 1 and 1.0 g/kg on day 3, particularly if serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL 1, 2
• Stage 2-3 acute kidney injury in cirrhosis: Withdraw diuretics and administer 1 g/kg body weight albumin daily for 2 consecutive days 1

Other Specific Indications

• Neonatal hemolytic disease: 1 g/kg body weight approximately 1 hour prior to exchange transfusion to bind free bilirubin 3
• Symptomatic hypovolemia with clinical signs (prolonged capillary refill, tachycardia, hypotension, oliguria) 1

When Albumin Infusion is NOT Recommended

Albumin should NOT be used for: 1, 2

• Routine correction of low serum albumin levels in critically ill patients
• First-line volume replacement in critical illness (excluding specific liver disease scenarios)
• Conjunction with diuretics for extravascular fluid removal
• Preterm neonates with respiratory distress and low albumin
• Prevention or treatment of intradialytic hypotension in kidney replacement therapy
• Pediatric patients undergoing cardiovascular surgery
• Maintaining albumin >3 g/dL post-liver transplant (does not improve outcomes) 1

Specific Population Management

Dialysis Patients

• Target serum albumin ≥4.0 g/dL (bromcresol green method) 1
• Ensure adequate nutrition monitored by renal dietitian with protein intake 1.2-1.3 g/kg/day 1
• Maintain adequate dialysis clearance (Kt/Vurea) 1
• Address inflammation when present by measuring C-reactive protein 1
• Monitor normalized protein nitrogen appearance (nPNA) with target ≥0.9 g/kg/day 1

Surgical Patients

• Preoperative albumin <3.0 g/dL is associated with increased surgical complications including infections and poor wound healing 1
• Preoperative nutritional assessment and optimization is recommended before elective surgery 1
• Correction of nutritional deficiency when feasible before cardiac surgery (Class IIa recommendation) 1

Administration Guidelines When Indicated

Dosing and rate: 3

• Plasbumin-25 (25% albumin) may be given undiluted or diluted in 0.9% saline or 5% dextrose
• In hypoproteinemia, rate should not exceed 2 mL per minute to avoid circulatory overload and pulmonary edema 3
• Total dose should not exceed 2 g per kg body weight in absence of active bleeding 3

Critical Pitfalls to Avoid

Common errors include: 1

• Assuming hypoalbuminemia equals malnutrition when inflammation is often the primary driver 1
• Routinely administering albumin without specific indication (wastes approximately $130 per 25g) 1
• Ignoring that aggressive nutrition may not correct albumin in the context of active inflammation or malignancy 1
• Failing to measure inflammatory markers (C-reactive protein) to distinguish inflammation-driven hypoalbuminemia from pure malnutrition 1

Adverse Effects of Albumin Administration

Potential complications include: 1, 2

• Fluid overload and pulmonary edema
• Hypotension
• Hemodilution requiring RBC transfusion
• Anaphylaxis
• Peripheral gangrene from dilution of natural anticoagulants

Monitoring Strategy

• Measure serum albumin regularly (at least every 4 months) 1
• Evaluate in clinical context, not as an isolated number 1
• Measure inflammatory markers (C-reactive protein) to identify inflammation as the cause 1
• Monitor response to treatment of underlying disease, not just albumin levels 1