How often can albumin (human albumin) orders be placed?

Albumin Order Frequency

The frequency of albumin orders depends entirely on the clinical indication: for spontaneous bacterial peritonitis (SBP), albumin is given as a two-dose regimen (within 6 hours of diagnosis and on day 3); for large-volume paracentesis, it is given once after the procedure; for hepatorenal syndrome, it may be given daily during vasoconstrictor therapy; and for congenital nephrotic syndrome with severe hypovolemia, daily infusions of 1-4 g/kg may be required initially, then tapered based on clinical response. 1, 2

Cirrhosis-Related Indications

Spontaneous Bacterial Peritonitis

• Albumin is administered as a two-dose protocol: 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1, 2
• This specific timing and dosing reduces kidney impairment by 72% and mortality by 47% in patients with elevated or rising creatinine 3
• No additional doses are indicated beyond this two-dose regimen for SBP 1, 2

Large-Volume Paracentesis (>5 Liters)

• Albumin is given once, after paracentesis completion, at a dose of 8 g per liter of ascites removed 1, 2
• For paracentesis <5 liters, synthetic plasma expanders (150-200 mL) can be used instead, and albumin is not required 1
• Orders are placed as needed when large-volume paracentesis is performed, not on a scheduled basis 2, 3

Hepatorenal Syndrome (HRS-AKI)

• For diagnostic volume expansion: 1 g/kg daily for 2 consecutive days (maximum 100 g/day) 1
• When used with vasoconstrictors for treatment, albumin may be continued daily throughout the vasoconstrictor therapy course, though specific duration varies by protocol 1
• The frequency is determined by the treatment response and duration of vasoconstrictor therapy 1

Congenital Nephrotic Syndrome

Severe Disease with Hypovolemia

• Daily albumin infusions of 1-4 g/kg may be initiated in patients with severe symptomatic hypovolemia (prolonged capillary refill, tachycardia, hypotension, oliguria) 1
• Frequency should be based on clinical indicators of hypovolemia rather than serum albumin levels 1
• As patients stabilize or chronic kidney disease progresses, the dose can be reduced and infusions made less frequent or stopped entirely 1

Stable Patients

• Some children with minimal symptoms do well without regular albumin infusions and do not require scheduled orders 1
• The decision to use regular protocols (versus as-needed administration) varies between centers, with no difference in long-term outcomes between strategies 1

Important Caveats

When NOT to Order Albumin Regularly

• Do not order albumin on a standing schedule for hypoalbuminemia correction alone, as this is not evidence-based and leads to inappropriate use 1, 2, 4
• Routine albumin for hospitalized cirrhosis patients with decompensation and hypoalbuminemia is not recommended and may increase adverse events 1
• Weekly or biweekly outpatient albumin for persistent ascites remains controversial and is not routinely recommended until further trials are completed 1

Monitoring Requirements

• The FDA mandates monitoring for circulatory overload during albumin administration, particularly with higher doses or rapid infusion 2
• Doses exceeding 87.5 g (>4×100 mL of 20% albumin) may worsen outcomes due to fluid overload in cirrhosis patients 2
• Volume status, cardiovascular status, and kidney function should be assessed before each administration 1

Cost Considerations

• At approximately $130 per 25 g, albumin's high cost supports restricting orders to well-defined, evidence-based indications 2, 3
• Inappropriate standing orders for hypoalbuminemia correction can lead to substantial unnecessary costs 5