What are the contraindications for albumin (human albumin) therapy in patients with various medical conditions, including severe anemia, cardiac failure, and liver disease?

Albumin Contraindications

Albumin is absolutely contraindicated in patients with a history of allergic reactions to albumin, and should be avoided in patients with congestive heart failure, renal insufficiency, and stabilized chronic anemia due to high risk of circulatory overload. 1

Absolute Contraindications

• History of allergic reaction to albumin is a specific contraindication to use 1
• Patients with documented hypersensitivity to albumin products must not receive albumin therapy 1

Relative Contraindications and High-Risk Populations

Cardiac Conditions

• Congestive heart failure represents a special risk for developing circulatory overload with albumin administration 1
• Patients with heart failure and hypoalbuminemia (≤2.9 g/dL) who receive albumin show increased in-hospital mortality and prolonged ICU/hospital stays 2
• Hypoalbuminemia in heart failure patients is independently associated with increased mortality risk, but albumin replacement does not improve outcomes and may worsen them 3, 2

Renal Disease

• Renal insufficiency places patients at special risk of circulatory overload 1
• Patients with acute kidney injury should receive albumin cautiously with careful volume status monitoring 4

Hematologic Conditions

• Stabilized chronic anemia is listed as a condition requiring special caution due to circulatory overload risk 1

Critical Safety Concerns with Albumin Use

Fluid Overload Risk

• Pulmonary edema and fluid overload are significant risks, particularly when targeting specific albumin levels rather than using for defined indications 5
• The ATTIRE trial demonstrated significantly higher rates of pulmonary edema when albumin was used to maintain serum albumin ≥3 g/dL in hospitalized cirrhosis patients 5
• Doses exceeding 87.5 g in spontaneous bacterial peritonitis patients are associated with worse outcomes due to fluid overload 5

Pulmonary Complications

• In cirrhosis patients with sepsis-induced hypotension, 20% albumin showed higher rates of pulmonary complications despite better shock reversal 5
• Albumin should be infused slowly to prevent cardiac overload, especially in patients with preexisting cardiomyopathy 5, 6

Clinical Scenarios Where Albumin Should Be Avoided

Inappropriate Indications

• Nutritional supplementation - albumin should never be used to correct hypoalbuminemia per se without hypovolemia 7
• Routine hypoalbuminemia correction in critically ill patients without specific liver-related indications 7, 8
• Broad resuscitation use in critically ill cirrhosis/ACLF patients is not well-defined and may cause harm 5

Heart Failure Specific

• Albumin administration in heart failure patients with serum albumin ≤2.9 g/dL is associated with increased mortality (p<0.001) 2
• No benefit demonstrated for albumin use in heart failure, only potential harm from volume overload 2

Monitoring Requirements to Prevent Complications

When albumin must be used despite risk factors, implement these safeguards:

• Cardiovascular monitoring: Assess for signs of fluid overload including jugular venous distension, pulmonary edema, and peripheral edema 6
• Respiratory monitoring: Watch for dyspnea, decreased oxygen saturation, and pulmonary crackles 6
• Volume status assessment: Use bedside transthoracic echocardiography to evaluate cardiac preload and function before and during administration 5, 4
• Renal function tracking: Monitor creatinine and urine output closely 6, 4

Common Pitfalls to Avoid

• Do not use albumin to "correct" low albumin levels in critically ill patients without specific indications (large-volume paracentesis >5L, spontaneous bacterial peritonitis, hepatorenal syndrome) 5, 7
• Do not exceed recommended doses - higher doses increase fluid overload risk without additional benefit 5
• Do not use in heart failure patients with hypoalbuminemia expecting benefit - evidence shows harm 2
• Do not infuse rapidly - slow administration is essential to prevent cardiac overload 5, 6

Additional Adverse Effects

Beyond contraindications, albumin can cause:

• Allergic and transfusion reactions 9
• Antibody formation 9
• Coagulation derangements 9
• Increased systemic inflammation in certain contexts 9