What is better for managing hypoalbuminemia, plasma transfusion or albumin injection?

Management of Hypoalbuminemia: Albumin Injection vs Plasma Transfusion

Neither albumin injection nor plasma transfusion is recommended for routine treatment of hypoalbuminemia in most clinical settings, as correcting low albumin levels does not improve mortality, morbidity, or quality of life. 1

Key Principle: Treat the Cause, Not the Number

• Hypoalbuminemia is a marker of underlying disease (inflammation, malnutrition, critical illness), not a therapeutic target in itself. 2
• Simply administering albumin to patients with low serum albumin has not been shown to improve survival or reduce morbidity in critically ill patients. 2
• The cause of hypoalbuminemia—rather than the low albumin level specifically—is responsible for adverse outcomes. 2

When Albumin IS Indicated (Use Albumin Injection, NOT Plasma)

If albumin therapy is warranted, use concentrated albumin solution (20-25%), never plasma transfusion, for the following specific indications:

Cirrhosis-Related Indications (Strong Evidence)

• Large-volume paracentesis >5L: Give 8g albumin per liter of ascites removed after the procedure is completed. 1
• Spontaneous bacterial peritonitis: Give 1.5 g/kg within 6 hours of diagnosis, then 1.0 g/kg on day 3 (use estimated dry weight). 1
• Hepatorenal syndrome: Albumin is part of standard management protocols. 3

Sepsis in Cirrhotic Patients

• 5% albumin is superior to crystalloids for reversing sepsis-induced hypotension in cirrhotic patients and improves short-term survival. 3

When Albumin Is NOT Recommended

General Critical Care (Strong Evidence Against)

• In critically ill adult patients (excluding thermal injuries and ARDS), intravenous albumin is NOT suggested for first-line volume replacement or to increase serum albumin levels. 1
• Albumin shows no mortality benefit compared to crystalloids (RR 0.98; 95% CI 0.92-1.06). 3
• Use balanced crystalloids (lactated Ringer's, Plasma-Lyte) instead, which are associated with reduced mortality compared to saline. 3

Other Settings Where Albumin Is Not Recommended

• Cardiovascular surgery: No mortality benefit or improvement in other outcomes. 1
• Intradialytic hypotension: Alternative strategies (higher dialysate calcium, lower dialysate temperature, individualized ultrafiltration rates) should be used first. 1
• Neonatal and pediatric critical care: No evidence of benefit. 1
• Admitted cirrhotic patients with hypoalbuminemia alone: No improvement in outcomes and increased adverse events. 1

Why NOT Plasma Transfusion?

Plasma transfusion is never the appropriate choice for hypoalbuminemia management:

• Plasma contains only 3-4 g of albumin per 100 mL unit, requiring massive volumes to meaningfully increase serum albumin. 1
• Concentrated albumin solutions (20-25%) provide 20-25g per 100 mL—far more efficient. 1
• Plasma carries additional risks: transfusion reactions, volume overload, infectious disease transmission, and TRALI (transfusion-related acute lung injury).
• All guidelines and trials examining albumin therapy use concentrated albumin solutions, not plasma. 1

Critical Safety Considerations for Albumin Use

When albumin IS used for appropriate indications, monitor carefully for:

• Fluid overload and pulmonary edema: Especially in patients with compromised cardiac/pulmonary function or cirrhosis (due to increased capillary permeability). 4
• Hypotension and tachycardia: Can paradoxically occur despite albumin being used to treat hypovolemia. 4
• Hemodilution: May require RBC transfusion to correct. 4
• Anaphylactic/allergic reactions: Including rash, pruritus, rigors, and pyrexia. 4
• Dose-dependent adverse effects: Higher doses carry greater risk. 4

Cost and Resource Considerations

• Albumin is expensive (approximately $130 per 25g in the United States) and manufactured from large volumes of donated plasma. 1
• There is a worldwide shortage of albumin. 1
• The cost of weekly albumin infusions for outpatient cirrhotic patients would be approximately $20,000 per patient annually. 1
• Given these constraints, albumin should be reserved strictly for evidence-based indications where it improves patient-important outcomes. 1

Common Pitfalls to Avoid

• Do not treat hypoalbuminemia as a laboratory abnormality requiring correction. The number itself is not the problem. 2
• Do not use plasma transfusion to "correct" albumin levels—it is ineffective and carries unnecessary risks.
• Do not give albumin to general critically ill patients for volume resuscitation—crystalloids are equally effective and less expensive. 1
• Do not assume all cirrhotic patients with low albumin need albumin—only specific complications (large-volume paracentesis, SBP, hepatorenal syndrome) benefit. 1