At what serum albumin level is albumin infusion indicated?

Albumin Infusion Indications Based on Clinical Context, Not Serum Level

Albumin infusion is NOT indicated based on a specific serum albumin threshold—decisions should be driven by clinical condition and specific diagnoses rather than laboratory values alone. The evidence consistently shows that correcting hypoalbuminemia per se does not improve outcomes and may cause harm.

Evidence-Based Indications for Albumin Administration

Cirrhosis-Related Indications (Strongest Evidence)

Large-Volume Paracentesis (>5 liters):

• Administer 8 g albumin per liter of ascites removed using 20% or 25% albumin solution 1
• Infuse after paracentesis completion to prevent post-paracentesis circulatory dysfunction 1, 2
• This indication has the strongest evidence base for albumin use 1

Spontaneous Bacterial Peritonitis:

• 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1, 2
• This regimen reduces renal dysfunction risk by 72% and mortality by 47% 2
• Dosing based on estimated dry weight 2

Hepatorenal Syndrome:

• Use albumin in combination with vasoconstrictors (terlipressin preferred) 1, 2
• For diagnostic workup: 1 g/kg/day up to 100 g/day for at least 2 days with diuretic withdrawal to assess response 1, 3
• Albumin administration should be guided by volume status rather than automatically given 1

Neonatal Hyperbilirubinemia (Specific Threshold Exists)

The only scenario where a serum albumin level triggers intervention:

• Consider albumin level <3.0 g/dL as one risk factor for lowering phototherapy threshold 1
• Measure serum albumin when considering exchange transfusion; use bilirubin/albumin ratio in conjunction with total serum bilirubin 1
• For isoimmune hemolytic disease: 1 g/kg body weight approximately 1 hour prior to exchange transfusion to bind free bilirubin 4

Congenital Nephrotic Syndrome (Symptom-Based, Not Level-Based)

• Base frequency and dosage on clinical indicators of hypovolemia (prolonged capillary refill, tachycardia, hypotension, oliguria, abdominal discomfort), not serum albumin levels 1
• In severe disease: daily albumin infusions of 1-4 g/kg may be initiated 1
• The purpose is supporting intravascular volume and reducing extravascular fluid retention, not normalizing serum albumin 1

Where Albumin is NOT Indicated

Critical Care Settings

General volume resuscitation:

• Albumin is not recommended as first-line treatment for volume expansion in critically ill adults 1, 3
• Isotonic crystalloids should be used first 1, 3
• Exception: When crystalloids fail or are contraindicated 5

Traumatic brain injury:

• Albumin is contraindicated—associated with increased mortality (RR 1.62) 3

Hypoalbuminemia alone:

• Never give albumin solely to correct low serum albumin levels 1, 2, 5
• Hypoalbuminemia is an acute phase reactant reflecting illness severity, not a treatment target 6
• Studies show hypoalbuminemia is infrequently associated with edema and plays a minor role in its formation 7

Nutritional support:

• Albumin has no role in nutritional interventions 5, 6
• Serum albumin should not be routinely ordered for nutritional monitoring in ICU patients 6

Other Conditions Without Strong Evidence

• Uncomplicated ascites in cirrhosis 2
• Nephrotic syndrome (routine use) 5
• Pancreatitis 5
• Abdominal surgery 5
• ARDS (unless specific criteria of hypoproteinemia with fluid overload) 4

Critical Caveats

Monitoring for adverse effects:

• Albumin can cause fluid overload, pulmonary edema, hypotension, hemodilution requiring transfusion, anaphylaxis, and peripheral gangrene 1, 2
• In cirrhosis with sepsis, 25% albumin may increase pulmonary complications 2

Cost considerations:

• Albumin costs approximately $130 per 25 g (warehouse acquisition cost) 1
• Inappropriate use represents significant healthcare waste 5

Pharmacokinetics:

• 58% of infused albumin is degraded rapidly 8, 2
• 100 mL of 25% albumin increases serum albumin by only 0.2-0.3 g/dL transiently 8
• Most infused albumin in nephrotic syndrome is lost in urine within hours 1

Peritoneal dialysis monitoring:

• While serum albumin should be monitored every 4 months as a prognostic marker, the goal is maintaining adequate nutrition and dialysis adequacy, not albumin infusion 1