Albumin Infusion in Nephrotic Syndrome in Adolescents
Albumin infusion should be reserved for adolescents with nephrotic syndrome who have clinical indicators of hypovolemia (prolonged capillary refill time, tachycardia, hypotension, oliguria, abdominal discomfort) or failure to thrive—not based on serum albumin levels alone. 1
Clinical Decision Algorithm
When to Use Albumin
Base the decision on clinical indicators of hypovolemia, not laboratory values: 1
- Signs requiring albumin consideration:
Do not administer albumin based solely on low serum albumin levels, as most infused albumin is lost in urine within hours and the goal is to support intravascular volume, not normalize albumin levels. 1
When to Avoid Albumin
Many adolescents with minimal or no symptoms do well without regular albumin infusions. 1 Avoid albumin in stable patients without clinical signs of hypovolemia. 1
Dosing Strategy
For Severe Disease with Symptomatic Hypovolemia
- Initial dose: 1-4 g/kg/day of albumin 1
- Frequency and dosage should be titrated based on clinical response to hypovolemia indicators, not serum albumin levels 1
For Stable or Improving Patients
- Reduce albumin dose and frequency as clinical status improves 1
- Consider spacing out or stopping albumin infusions entirely in stable patients 1
- As chronic kidney disease progresses, albumin may be reduced or discontinued 1
Combination with Diuretics
Consider administering furosemide 0.5-2 mg/kg IV bolus at the end of each albumin infusion in the absence of marked hypovolemia or hyponatremia. 1 This combination may enhance diuresis and natriuresis more effectively than furosemide alone. 2
A 2022 systematic review found that urine excretion was greater after treatment with furosemide and albumin versus furosemide alone (SMD 0.85,95% CI 0.33-1.38), though the overall evidence quality remains limited. 3
Critical Safety Considerations
Vascular Access Risks
Avoid central venous lines whenever possible due to high risk of thrombosis and the need to preserve vasculature for future hemodialysis access. 1
If regular albumin infusions are inevitable and a central line is required:
- Administer prophylactic anticoagulation for as long as the line is in place 1
- Avoid peripherally inserted catheters and unnecessary venepunctures to preserve vessels for potential arteriovenous fistulae 1
Diuretic Administration
Use diuretics with caution—only in cases of intravascular fluid overload (good peripheral perfusion and high blood pressure), as they can induce or worsen hypovolemia and promote thrombosis. 1
Furosemide infusions must be administered over 5-30 minutes to avoid ototoxicity. 1, 4
High doses of furosemide (>6 mg/kg/day) should not be given for more than 1 week due to risk of permanent hearing loss. 1, 5, 4
Common Pitfalls to Avoid
Do not use serum albumin levels as the sole indication for albumin infusion—this leads to unnecessary treatment and increased complications. 1
Do not administer albumin or diuretics in patients with marked hypovolemia, hypotension, severe hyponatremia, or anuria, as this worsens outcomes. 1, 4
Avoid routine albumin infusions in asymptomatic patients—retrospective studies show no difference in long-term outcomes between regular albumin protocols and as-needed administration. 1
Consider quality of life and school attendance when deciding on regular albumin infusions, as they may require prolonged hospitalization or frequent clinic visits. 1
Evidence Quality Note
While the 2021 ERKNet-ESPN consensus guidelines provide the most comprehensive framework for albumin use in pediatric nephrotic syndrome [1-1], the research evidence remains limited. A 2019 Cochrane review found only one small study meeting inclusion criteria and concluded that insufficient evidence exists to draw definitive conclusions. 6 However, the guideline recommendations are based on expert consensus and clinical experience in managing this complex condition, prioritizing prevention of hypovolemic complications and thrombosis over laboratory normalization.