When is albumin infusion therapy necessary and how is it administered in cases of low albumin levels?

Albumin Infusion: Evidence-Based Indications and Administration

Albumin infusion is indicated for specific cirrhosis complications—large-volume paracentesis (>5L), spontaneous bacterial peritonitis, and hepatorenal syndrome—but should not be used routinely for hypoalbuminemia alone or general volume resuscitation. 1, 2

Clear Indications for Albumin Use

Large-Volume Paracentesis

• Administer 8g albumin per liter of ascites removed after paracentesis >5L is completed 1, 2
• Use 20% or 25% albumin solution 1
• This prevents post-paracentesis circulatory dysfunction, which leads to renal impairment and increased mortality 2, 3
• For paracentesis <5L, albumin may be considered only in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1

Spontaneous Bacterial Peritonitis (SBP)

• Infuse 1.5 g/kg albumin within 6 hours of SBP diagnosis, followed by 1.0 g/kg on day 3 1, 2
• This dosing reduces hepatorenal syndrome incidence from 30% to 10% and mortality from 29% to 10% 1
• Particularly effective when baseline serum bilirubin ≥68 μmol/L (4 mg/dL) or serum creatinine ≥88 μmol/L (1 mg/dL) 1
• The benefit is unclear in patients with bilirubin <68 μmol/L and creatinine <88 μmol/L, though current guidelines recommend treating all SBP patients with albumin 1

Hepatorenal Syndrome

• Albumin is uniformly administered in combination with vasoconstrictors (such as terlipressin) for hepatorenal syndrome treatment 2, 3
• Specific dosing protocols vary but albumin is considered essential therapy 2

When Albumin is NOT Indicated

Do Not Use For:

• Hypoalbuminemia alone—serum albumin concentration does not reflect albumin function in liver disease 2, 3
• Routine volume replacement in critically ill patients—crystalloids are equally effective and far less expensive 2, 3
• Cardiovascular surgery patients—no demonstrated benefit over alternatives 2, 3
• Nutritional supplementation—albumin is not appropriate for nutritional purposes 4, 5
• Intradialytic hypotension—not recommended for routine use 2

Administration Considerations

Practical Dosing Details

• For SBP: Base dosing on estimated dry weight (1.5 g/kg then 1.0 g/kg), though calculating dry weight in cirrhotic patients can be challenging 3
• For paracentesis: Calculate total dose as 8g × liters removed (e.g., 6L removed = 48g albumin) 1, 2
• Administer after paracentesis completion, not during the procedure 1, 2

Critical Safety Monitoring

• Fluid overload is the primary complication, particularly with doses >87.5g (>4×100mL of 20% albumin) 2
• Monitor for circulatory overload during administration—this is an FDA-mandated requirement 2
• Watch for hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene from dilution of natural anticoagulants 2
• Patients with increased or rising serum creatinine require especially careful monitoring 1, 2

Concentration Selection

• Use 20% or 25% albumin solutions for cirrhosis indications 1, 2
• In sepsis-induced hypotension with cirrhosis, 5% albumin showed better 1-week survival (43.5% vs 38.3%) compared to normal saline, though 25% albumin may increase pulmonary complications 3

Special Populations

Congenital Nephrotic Syndrome (Pediatric)

• Albumin infusions (1-4 g/kg/day) may be necessary for symptomatic hypovolaemia 1
• Base frequency and dosage on clinical indicators (prolonged capillary refill, tachycardia, hypotension, oliguria, abdominal discomfort) rather than serum albumin levels 1
• Avoid central venous lines when possible due to thrombosis risk and need to preserve vasculature for future dialysis access 1
• When albumin infusions are inevitable and a central line is required, administer prophylactic anticoagulation 1

Cost Considerations

• Albumin costs approximately $130 per 25g, making it substantially more expensive than crystalloids 2, 3
• This high cost supports restricting use to well-defined, evidence-based indications 2, 3

Areas of Ongoing Debate

• Long-term outpatient albumin therapy for refractory ascites is under investigation but not currently recommended by guidelines 3, 6
• Use in infections other than SBP, hyponatremia, and hepatic encephalopathy remains controversial with inconclusive evidence 6, 4
• The optimal amount, frequency, and patient selection criteria require further refinement 6