What is the recommended dose of intravenous (IV) albumin for a patient requiring volume expansion or serum albumin level correction?

IV Albumin Dosing

Albumin should NOT be used routinely for volume expansion or correcting low albumin levels in most hospitalized patients, but when indicated for specific cirrhosis complications, use 1.5 g/kg for spontaneous bacterial peritonitis or 8 g/L of ascites removed for large-volume paracentesis (>5L). 1

When Albumin IS Indicated

Cirrhosis-Related Complications

Large-Volume Paracentesis (>5L)

• Administer 8 g of albumin per liter of ascites removed after the procedure is completed 1, 2
• In patients with acute-on-chronic liver failure (ACLF), use 6-8 g/L regardless of volume removed 1
• Maximum safe dose should not exceed 87.5 g (approximately 4×100 mL of 20% albumin) to avoid fluid overload 2

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5 g/kg within 6 hours of diagnosis 1, 2
• Follow with 1.0 g/kg on day 3 1, 2
• This dosing reduces kidney impairment and mortality 2

Hepatorenal Syndrome (HRS-AKI)

• Initial dose: 1 g/kg (maximum 100 g) on day 1 3
• Maintenance: 20-40 g/day during vasoconstrictor therapy 3
• Must be used in conjunction with vasoconstrictors like terlipressin 1

Other Specific Indications

Hypovolemic Shock (when indicated)

• Total dose should not exceed 2 g/kg body weight in the absence of active bleeding 4
• 25% albumin expands plasma volume by 3-4 times the infused volume by drawing fluid from interstitial spaces 4

Burns (after 24 hours)

• Target plasma albumin concentration of 2.5 ± 0.5 g/100 mL 4
• Use 25% albumin to maintain plasma oncotic pressure at 20 mm Hg 4

When Albumin Should NOT Be Used

The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommend AGAINST albumin in: 1

• First-line volume replacement in critically ill adults (excluding thermal injuries and ARDS) 1
• Correcting hypoalbuminemia alone without specific complications 1, 2
• Routine use in cardiovascular surgery 1
• Intradialytic hypotension as routine therapy (costs ~$20,000 annually per patient with no proven superiority) 2, 5
• Pediatric and neonatal critical care patients 2
• Uncomplicated ascites in cirrhosis 1
• Chronic nephrosis, malabsorption, or protein-losing enteropathies 4

Administration Guidelines

Infusion Rate

• In hypoproteinemic patients: do not exceed 2 mL/minute to avoid circulatory overload and pulmonary edema 4
• Maximum safe dose is 100 g per day for initial loading 3

Preparation

• May be given undiluted or diluted in 0.9% saline or 5% dextrose 4
• If sodium restriction required, use only 5% dextrose 4
• Use only 16-gauge needles for vials 20 mL or larger 4

Critical Safety Considerations

Contraindications

• Active pulmonary edema 3
• Severe cardiac dysfunction 3
• SpO2 <90% 3

Monitoring Requirements

• Watch for fluid overload, particularly in cirrhotic patients receiving higher doses 2
• Monitor patients with rising serum creatinine carefully 2
• FDA mandates monitoring for circulatory overload 2

Documented Complications

• Fluid overload and pulmonary edema 1, 2
• Hypotension 1, 2
• Hemodilution requiring RBC transfusion 1
• Anaphylaxis 1
• Peripheral gangrene from dilution of natural anticoagulants 1

Common Pitfalls to Avoid

Do not use albumin to "correct" low albumin levels - this does not improve outcomes and increases albumin degradation by 39% 3

Crystalloids remain first-line for volume resuscitation - minimum 30 mL/kg crystalloid bolus should be given first in most scenarios 3

Cost considerations matter - albumin costs approximately $130 per 25 g dose, substantially more than crystalloids, with no mortality benefit in general critical care populations 1, 2