What is the role of albumin in managing hypotension?

Role of Albumin in Hypotensive Patients

The role of albumin in hypotension depends critically on the underlying etiology: albumin is recommended for sepsis-induced hypotension in cirrhotic patients and for specific liver-related indications, but is NOT recommended as first-line volume replacement in general critically ill hypotensive patients.

Cirrhotic Patients with Sepsis-Induced Hypotension

In patients with cirrhosis and sepsis-induced hypotension, 5% albumin is superior to crystalloids for reversing hypotension and improving short-term survival. 1

• A randomized trial of 308 cirrhotic patients with sepsis-induced hypotension demonstrated that 5% albumin achieved higher rates of hypotension reversal at 1 hour (25.3% vs 11.7%, p=0.03) and 3 hours (11.7% vs 3.2%, p=0.008) compared to normal saline 2
• This same trial showed improved 1-week survival with albumin (43.5% vs 38.3%, p=0.03) 1, 2
• Albumin reduces systemic inflammation and circulatory dysfunction in decompensated cirrhosis 1

Important caveat: A trial comparing 20% albumin with Plasma-Lyte showed higher shock reversal rates but no survival benefit and increased pulmonary complications, highlighting the risk of fluid overload 1

Specific Liver-Related Indications for Albumin

Albumin is definitively recommended for these cirrhosis-related scenarios: 1

• Large-volume paracentesis (>5L): 8g albumin per liter of ascites removed to prevent paracentesis-induced circulatory dysfunction 1, 3
• Spontaneous bacterial peritonitis: 1.5 g/kg on day 1 and 1.0 g/kg on day 3 1, 3
• Hepatorenal syndrome: Part of standard management 1

General Critically Ill Hypotensive Patients (Non-Cirrhotic)

Albumin is NOT recommended as first-line volume replacement in general critically ill hypotensive patients. 1, 3

• The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly state that intravenous albumin is not suggested for volume replacement or to increase serum albumin level in critically ill adult patients (conditional recommendation) 1
• Meta-analyses of critically ill patients without cirrhosis show no mortality benefit when albumin is compared to crystalloids (RR 0.98; 95% CI 0.92-1.06) 1
• Balanced crystalloids (lactated Ringer's, Plasma-Lyte) are associated with reduced mortality compared to saline in general critically ill populations 1

Intradialytic Hypotension

For hospitalized hypoalbuminemic patients (albumin <3.0 g/dL) requiring hemodialysis, albumin infusion may prevent intradialytic hypotension, but routine use is not recommended. 1

• A 2021 randomized crossover trial (n=65) found that 100ml of 25% albumin at dialysis initiation reduced hypotension episodes (15% vs 7%, p=0.002) and improved ultrafiltration rates compared to saline 4
• However, the 2024 ICTMG guidelines do not suggest routine albumin use for intradialytic hypotension due to high cost (~$20,000 annually per patient for thrice-weekly use) and lack of large-scale evidence 1
• Alternative strategies should be prioritized: higher dialysate calcium, lower dialysate temperature, individualized ultrafiltration rates, or midodrine 1

Critical Safety Considerations

Albumin carries significant risks of fluid overload, particularly in patients with cirrhosis or compromised cardiac/pulmonary function: 5

• Pulmonary edema and fluid overload are dose-dependent adverse effects 5
• The ATTIRE trial (777 patients with decompensated cirrhosis) showed that targeting albumin levels >3.0 g/dL was associated with significantly higher rates of pulmonary edema without improving outcomes 1
• Patients with cirrhosis have increased capillary permeability and compromised lymphatic drainage, increasing risk 5

Practical Algorithm for Albumin Use in Hypotension

Step 1: Identify the underlying cause of hypotension

• Hypovolemic vs vasodilatory vs cardiogenic shock 1
• Assess with bedside transthoracic echocardiography for preload, cardiac function, and fluid status 1

Step 2: Determine if patient has cirrhosis

• If YES and sepsis-induced hypotension: Use 5% albumin as resuscitation fluid 1, 2
• If YES with specific indications (large-volume paracentesis, SBP, HRS): Use albumin per established protocols 1, 3
• If NO cirrhosis: Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) as first-line 1

Step 3: Monitor for fluid overload during resuscitation

• Track stroke volume variation, pulse pressure variation, or serial TTE assessments 1
• Watch for respiratory distress, pulmonary rales, peripheral edema 5

Step 4: Add vasopressors if hypotension persists despite adequate fluid resuscitation

• Target MAP ≥65 mmHg 1
• Vasopressors should be used concurrently with ongoing fluid resuscitation, not as replacement 1

Common Pitfalls to Avoid

• Do not use albumin to "correct" low serum albumin levels in general critically ill patients - this approach showed no benefit and increased pulmonary complications 1, 3
• Do not assume albumin is a superior volume expander in all contexts - clinical trials show it is not as effective as theoretical oncotic properties suggest 6
• Do not ignore the high cost - albumin costs approximately $130 per 25g, making routine use economically unsustainable without clear benefit 3
• Do not overlook alternative causes of hypotension - address underlying sepsis, bleeding, cardiac dysfunction rather than reflexively administering albumin 3