When is albumin (human albumin) transfusion indicated?

When to Transfuse Albumin: Evidence-Based Indications

Albumin transfusion has only two well-established indications: cirrhosis-related complications (large-volume paracentesis and spontaneous bacterial peritonitis) and should NOT be used for routine volume resuscitation, to correct low albumin levels, or for nutritional purposes. 1, 2, 3

Evidence-Based Indications (Strong Recommendations)

Cirrhosis-Related Complications

Large-Volume Paracentesis (>5L)

• Administer 8g of albumin per liter of ascites removed using 20% or 25% solution to prevent post-paracentesis circulatory dysfunction 1, 3, 4
• This is the most robust indication with conditional recommendation from the American Thoracic Society 2, 3

Spontaneous Bacterial Peritonitis

• Give 1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 1
• This reduces renal dysfunction by 72% and mortality by 47% 1
• Conditional recommendation with moderate certainty of evidence 2, 3

Situations Where Albumin is NOT Indicated

Do NOT Use Albumin For:

Volume Resuscitation in Critical Illness

• The American Thoracic Society recommends AGAINST albumin for first-line volume replacement in critically ill adults (excluding thermal injuries and ARDS) 1, 2, 3
• Crystalloids remain the first-line choice with moderate certainty of evidence 3

Correcting Low Albumin Levels

• Critical pitfall: Low serum albumin is a marker of disease severity, NOT a treatment target 1, 3
• Albumin infusion cannot reverse underlying causes such as inflammatory cytokines suppressing synthesis and increased transcapillary loss 1
• The American Thoracic Society explicitly recommends against using serum albumin concentration as an indication for albumin administration 1, 3

Chronic Hypoalbuminemic States

• Chronic nephrosis: infused albumin is promptly excreted with no relief of edema 4
• Chronic cirrhosis, malabsorption, protein-losing enteropathies: albumin as nutritional support is not justified 4
• Does not improve survival or functional outcomes in chronic hypoalbuminemia 1

Pediatric and Neonatal Critical Care

• Not recommended for routine use in neonatal critical care 2
• Not recommended for respiratory distress in preterm neonates ≤36 weeks 3
• Not recommended for volume replacement in neonates ≤32 weeks or ≤1,500g 3

Cardiovascular Surgery

• Not recommended for routine use in cardiovascular surgery 2, 3
• Not recommended for priming bypass circuits in pediatric cardiovascular surgery 3

Kidney Replacement Therapy

• Not recommended for prevention or treatment of intradialytic hypotension 3, 5
• Not recommended for improving ultrafiltration 3, 5
• Despite theoretical benefits, clinical trials show albumin is not as effective a volume expander as predicted by oncotic properties 5

Potential But Controversial Indications (Weak Evidence)

The FDA label lists additional indications, but these lack strong guideline support and should be considered only as second-line adjunctive therapy 4:

Burns (Beyond 24 Hours)

• May be used to maintain plasma colloid osmotic pressure after initial crystalloid resuscitation 4

Acute Liver Failure

• May support colloid osmotic pressure and bind excess bilirubin 4

Neonatal Hemolytic Disease

• 1g/kg given 1 hour prior to exchange transfusion to bind free bilirubin 4

Hypovolemic Shock (Specific Circumstances)

• Only when there is oncotic deficit or long-standing shock with delayed treatment 4
• Must be combined with appropriate crystalloids 4

Significant Risks and Adverse Effects

Common Complications:

• Fluid overload and pulmonary edema (especially if infused >2 mL/min in hypoproteinemic patients) 1, 3
• Hypotension 1, 2, 3
• Hemodilution requiring RBC transfusion 1, 2, 3
• Anaphylaxis 1, 2, 3
• Peripheral gangrene from dilution of natural anticoagulants 2, 3

Clinical Decision Algorithm

Step 1: Identify the clinical scenario

• Does the patient have cirrhosis with large-volume paracentesis (>5L) or spontaneous bacterial peritonitis? → YES: Use albumin 1, 2, 3
• Is this any other scenario? → Proceed to Step 2

Step 2: Assess if albumin is being considered to "correct" low albumin

• Is the primary reason a low serum albumin level? → NO: Do not use albumin 1, 3
• Low albumin reflects illness severity and treating the number does not improve outcomes 1, 3

Step 3: Evaluate goals of care

• Are you considering albumin for volume resuscitation in critical illness? → Use crystalloids first-line instead 1, 2, 3
• Is this for chronic hypoalbuminemia (nephrosis, malnutrition, chronic cirrhosis)? → Do not use albumin 4

Step 4: Cost-benefit analysis

• Albumin costs approximately $130 per 25g, substantially more than crystalloids 1, 3
• Of 14 guideline recommendations, 12 recommend AGAINST albumin use in common clinical scenarios 3

Key Takeaway

The overwhelming evidence supports restricting albumin use to cirrhosis-related complications only. The American Thoracic Society, American Association for the Study of Liver Diseases, and FDA guidance converge on this narrow indication, while explicitly recommending against its use in the vast majority of clinical scenarios where it is commonly considered 1, 2, 3, 4. Treat the underlying disease causing hypoalbuminemia, not the laboratory value itself 1, 2.