When is albumin (human albumin) administered for edema and hypotension (low blood pressure)?

When to Give Albumin for Edema and Low Blood Pressure

Albumin is generally NOT recommended for edema and hypotension in most clinical scenarios, with the critical exception of specific liver disease complications. 1

Primary Indication: Liver Disease Complications

For patients with cirrhosis, albumin has proven mortality benefit only in spontaneous bacterial peritonitis (SBP) and large-volume paracentesis (>5L). 1

Spontaneous Bacterial Peritonitis

• Administer albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3 alongside antibiotics 1
• This reduces kidney impairment (10% vs 33%, P=0.002) and in-hospital mortality (10% vs 29%, P=0.01) 1
• The mortality benefit (OR 0.34,95% CI 0.19-0.60) and renal protection (OR 0.21,95% CI 0.11-0.42) are well-established 1

Large-Volume Paracentesis

• Give albumin 8 g per liter of ascitic fluid removed when removing >5L 2, 3
• This prevents post-paracentesis circulatory dysfunction 1, 2
• Administer during or after the procedure, then resume diuretics 2

When NOT to Use Albumin for Edema and Hypotension

Critical Care/Sepsis

Albumin does NOT improve mortality or meaningful outcomes in critically ill patients with sepsis and hypotension, despite theoretical benefits. 1

• The SAFE trial (N=6,997) and ALBIOS trial (N=1,818) showed no mortality benefit (RR 1.00,95% CI 0.87-1.14) 1
• The 2021 Surviving Sepsis Campaign suggests albumin only as a rescue fluid when patients require large volumes of crystalloids, but this is a weak recommendation 1
• Crystalloids remain first-line for septic shock resuscitation 1

Edema with Diuretics

The combination of albumin plus furosemide does NOT improve mortality, ventilator-free days, or clinical outcomes in critically ill patients with edema. 1, 2, 4

• A 2014 systematic review (10 studies, N=343) found no difference in 24-hour urine output despite theoretical benefits 1
• A 2022 systematic review (3 trials, N=129) showed albumin-furosemide reduced hypotensive episodes but did not improve ventilator duration or mortality 1
• This combination does not work for general edema management 2, 4

Chronic Hypoalbuminemia

Albumin infusion is NOT warranted for chronic hypoproteinemic states causing edema. 3

• In chronic nephrosis, infused albumin is promptly excreted with no relief of edema 3
• In chronic cirrhosis, malabsorption, and malnutrition, albumin as protein nutrition is not justified 3
• Hypoalbuminemia itself rarely causes edema—most edema has other identifiable causes 5

Critical Safety Concerns

Risk of Pulmonary Edema

Albumin carries significant risk of fluid overload and pulmonary edema, particularly in patients with cardiac or pulmonary compromise. 1, 4

• In cirrhotic patients with extraperitoneal infections, albumin increased pulmonary edema rates (OR 5.17,95% CI 1.62-16.47) 1
• The ATTIRE trial (N=777) in decompensated cirrhosis showed more severe adverse events with albumin, primarily pulmonary edema 1
• Infusion rate should not exceed 2 mL/minute in hypoproteinemic patients to prevent circulatory embarrassment 3

Paradoxical Hypotension

Albumin can paradoxically cause hypotension despite intended volume expansion, especially in patients on ACE inhibitors. 4, 6

• 11% of cardiac surgery patients experienced paradoxical hypotension with 4% albumin infusion 6
• This effect is significantly more common in patients taking ACE inhibitors preoperatively (P=0.04) 6
• The mechanism involves bradykinin generation through pre-kallikrein activator 6

Contraindications

Avoid albumin in patients with: 4

• Marked hypovolemia or severe hyponatremia
• Anuria
• Compromised cardiac or pulmonary function
• Current ACE inhibitor therapy (use with extreme caution) 6

Practical Algorithm for Decision-Making

Step 1: Identify the underlying cause

• Cirrhosis with SBP → Give albumin (1.5 g/kg day 1.0 g/kg day 3) 1
• Cirrhosis with paracentesis >5L → Give albumin (8 g/L removed) 2, 3
• Septic shock/critical illness → Use crystalloids first-line; albumin NOT recommended 1
• Chronic hypoalbuminemia/nephrotic syndrome → Albumin NOT indicated 3, 7

Step 2: If considering albumin despite lack of strong indication

• Check for ACE inhibitor use (high risk of paradoxical hypotension) 6
• Assess cardiac/pulmonary function (high risk of pulmonary edema) 1, 4
• Calculate cost-benefit ratio (~$130 per 25g with no proven mortality benefit in most scenarios) 4

Step 3: If administering albumin

• Infuse slowly (≤2 mL/minute in hypoproteinemic patients) 3
• Monitor closely for fluid overload, blood pressure changes, and respiratory status 2, 4
• If combining with furosemide, give furosemide within 2 hours after albumin 2
• Infuse furosemide over 5-30 minutes to minimize ototoxicity 2

Bottom Line

The evidence strongly supports albumin use only in cirrhotic patients with SBP or undergoing large-volume paracentesis. 1, 2 For general edema and hypotension in critical illness, sepsis, or chronic hypoalbuminemia, albumin provides no mortality benefit and carries significant risks of pulmonary edema and paradoxical hypotension. 1, 4 Crystalloids remain the appropriate first-line therapy for volume resuscitation in nearly all other scenarios. 1