How is low albumin (hypoalbuminemia) treated?

Treatment of Hypoalbuminemia

Treat the underlying cause of hypoalbuminemia rather than the low albumin level itself, with albumin infusion reserved only for specific liver disease complications (large-volume paracentesis >5L and spontaneous bacterial peritonitis). 1

Primary Treatment Strategy

The cornerstone of managing hypoalbuminemia is identifying and addressing the root cause rather than simply correcting the number 1, 2. This approach is critical because:

• Inflammation, not malnutrition alone, is typically the primary driver of low albumin in acute and chronic illness, as inflammatory cytokines directly suppress hepatic albumin synthesis even when protein and caloric intake are adequate 1, 3
• Hypoalbuminemia develops slowly from malnutrition alone but rapidly from inflammatory redistribution or crystalloid dilution 3
• Simply administering albumin to critically ill patients has not been shown to improve survival or reduce morbidity 2, 4

Address Underlying Causes

• Treat active inflammation as the priority, since it is often a more powerful predictor of poor outcomes than the low albumin itself 1
• Correct fluid overload, as hemodilution from excess crystalloid administration decreases serum albumin concentration 1
• Minimize external protein losses by treating proteinuria or reducing dialysate losses in peritoneal dialysis patients 1
• Optimize liver function if hepatic dysfunction is contributing 3

Nutritional Support

• Provide adequate protein intake of 1.2-1.3 g/kg body weight per day combined with sufficient calories (30-35 kcal/kg/day for patients ≥60 years; 35 kcal/kg/day for those <60 years) 1
• Focus on high-protein foods including lean meats (chicken, turkey, lean beef), fish and seafood (20-25g protein per 3-4 oz serving), eggs, dairy products, legumes, and soy products 1
• Monitor normalized protein nitrogen appearance (nPNA) with target ≥0.9 g/kg/day in dialysis patients 1

When Albumin Infusion IS Indicated

Albumin administration should be limited to these specific scenarios:

Liver Disease Complications

• Large-volume paracentesis (>5L): 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 (patients with serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL benefit most) 1, 5
• Stage 2-3 acute kidney injury in cirrhosis with ascites: Withdraw diuretics immediately and administer 1 g/kg body weight albumin daily for 2 consecutive days 1

When Albumin Infusion Is NOT Recommended

The American Thoracic Society explicitly recommends against albumin infusion in the following situations 1, 5:

• First-line volume replacement in critically ill adult patients (excluding thermal injuries and ARDS) 1, 5
• To increase serum albumin levels in critically ill patients with thermal injuries or ARDS 1
• In conjunction with diuretics for removal of extravascular fluid 1
• For preterm neonates with respiratory distress and low serum albumin 1
• For patients undergoing kidney replacement therapy for prevention or treatment of intradialytic hypotension 1
• For pediatric patients undergoing cardiovascular surgery 1
• For other infections in cirrhosis (increases pulmonary edema without benefit) 1

Monitoring and Target Goals

• Measure C-reactive protein or other inflammatory markers to distinguish inflammation-driven hypoalbuminemia from pure malnutrition 1
• Target serum albumin ≥4.0 g/dL (using bromcresol green method) in dialysis patients 1
• Monitor serum albumin at least every 4 months and evaluate in context of overall clinical status including comorbid diseases 1
• For surgical patients, recognize that albumin <3.0 g/dL is associated with increased risk of complications including surgical site infections and poor wound healing 1

Common Pitfalls to Avoid

• Do not assume hypoalbuminemia is solely due to nutritional deficiency when inflammation may be the primary driver 1
• Do not use albumin infusion as routine treatment for low albumin levels outside the specific liver disease indications 1, 5
• Recognize that albumin is expensive (approximately $130/25g USD) and carries risks including fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene 1, 5
• In dialysis patients with high urea levels, prioritize effective dialysis to remove excess urea rather than albumin administration 1

Special Populations

Dialysis Patients

• Ensure adequate dialysis clearance (Kt/Vurea) 1
• Hemodialysis patients require at least 1.2 g protein/kg/day 1
• Peritoneal dialysis patients require at least 1.3 g protein/kg/day due to protein losses in dialysate 1

Surgical Patients

• Preoperative nutritional assessment and optimization is recommended for patients with albumin <3.0 g/dL 1
• Hypoalbuminemia <3.0 g/dL reflects disease-associated catabolism and disease severity, not just nutritional status 1

Patients on Corticosteroids

• Use steroids for the shortest time possible with downward titration whenever feasible 1
• Monitor nutritional status in patients requiring long-term steroid therapy, as steroids drive catabolism and worsen hypoalbuminemia 1