When is albumin (human albumin) indicated for patients undergoing blood transfusion (BT)?

Albumin Administration During Blood Transfusion

Albumin is NOT routinely indicated during blood transfusion, with the exception of specific scenarios involving erythrocyte resuspension where approximately 25g of albumin per liter of washed or previously frozen red cells may be used to prevent excessive hypoproteinemia. 1

Evidence-Based Indications Related to Blood Transfusion

Erythrocyte Resuspension (Limited Indication)

• Albumin may be required during certain types of exchange transfusion or when using very large volumes of previously frozen or washed red cells to avoid excessive hypoproteinemia 1
• The standard practice is approximately 25g of albumin per liter of erythrocytes, though requirements may be greater in patients with preexistent hypoproteinemia or hepatic impairment 1
• Plasbumin-25 should be added to the isotonic suspension of washed red cells immediately prior to transfusion 1

Neonatal Hemolytic Disease (Specific Exception)

• Albumin administration may be indicated prior to exchange transfusion to bind free bilirubin and reduce the risk of kernicterus 1
• The recommended dosage is 1g/kg body weight given approximately 1 hour prior to exchange transfusion 1
• Caution must be observed in hypervolemic infants 1

Why Albumin is NOT Routinely Used During Blood Transfusion

General Volume Replacement

• The 2024 International Collaboration for Transfusion Medicine Guidelines made 14 recommendations on albumin use, with 12 of 14 recommendations advising AGAINST albumin use in common clinical scenarios 2, 3
• Albumin is not recommended for first-line volume replacement in critically ill adults (excluding thermal injuries and ARDS), with moderate certainty of evidence 3
• Low serum albumin is a marker of illness severity, not a treatment target 3

Cost Considerations Without Proven Benefit

• Albumin costs approximately $130 per 25g, substantially more expensive than crystalloids without proven superiority in most settings 3
• The high cost without demonstrated benefit for improving patient-important outcomes makes routine use economically unsustainable 4

Critical Clinical Pitfalls to Avoid

Do Not "Correct" Low Albumin Levels

• Albumin should NOT be administered simply to "correct" a low albumin level, as it does not improve outcomes 3
• In chronic hypoproteinemic states, infused albumin does not provide therapeutic benefit and is not justified as a source of protein nutrition 1

Potential Adverse Effects During Transfusion

• Fluid overload and pulmonary edema, especially if infused >2 mL/min in hypoproteinemic patients 3
• Hemodilution requiring additional RBC transfusion 3
• Hypotension 3
• Anaphylaxis 3
• Peripheral gangrene from dilution of natural anticoagulants 3

Monitoring Requirements

• Patients must always be monitored carefully to guard against circulatory overload 1
• The rapid rise in blood pressure following albumin administration necessitates careful observation to detect and treat severed blood vessels which may not have bled at lower blood pressure 1

When Albumin IS Indicated (Unrelated to Routine Transfusion)

The only strong evidence-based indications for albumin are:

• Large-volume paracentesis (>5L) in cirrhotic patients to prevent paracentesis-induced circulatory dysfunction 3
• Spontaneous bacterial peritonitis in cirrhotic patients 3

These cirrhosis-related indications have conditional recommendations with very low certainty of evidence but represent the most accepted uses of albumin in current practice 2.