Albumin Administration in Nephrotic Syndrome
Albumin infusions should be reserved for patients with nephrotic syndrome who demonstrate clinical signs of hypovolemia—not administered based on serum albumin levels alone. 1, 2
Clinical Indications for Albumin
Albumin is indicated only when patients exhibit specific clinical markers of intravascular volume depletion, including: 1, 2
- Prolonged capillary refill time
- Tachycardia
- Hypotension
- Oliguria or acute kidney injury
- Abdominal discomfort suggesting hypovolemia
- Failure to thrive
The purpose of albumin infusion is to support intravascular volume and reduce extravascular fluid retention—not to normalize serum albumin levels. 1, 3 Most infused albumin is lost in urine within hours, making serum albumin level correction futile. 1
When NOT to Give Albumin
Do not administer albumin in the following situations: 2, 4
- Asymptomatic patients with low albumin but no signs of hypovolemia—retrospective studies show no difference in long-term outcomes between regular albumin protocols versus as-needed administration 1
- Chronic nephrosis without acute hypovolemia—infused albumin is promptly excreted by kidneys with no relief of chronic edema 5
- Patients with marked hypovolemia, severe hyponatremia, or anuria (must correct these first before considering albumin) 2, 4
Dosing Strategy When Indicated
When clinical indicators warrant albumin use: 1, 2
- Initial dose: 1-4 g/kg/day IV
- Titration: Base frequency and dosage on clinical response to hypovolemia indicators, not serum albumin levels
- Combination therapy: Administer furosemide 0.5-2 mg/kg IV bolus at the end of each albumin infusion (only in absence of marked hypovolemia or hyponatremia) 1, 4
- De-escalation: As clinical status improves, reduce albumin dose and frequency; consider spacing out or stopping infusions entirely in stable patients 1, 2
Critical Safety Considerations
Central venous lines should be avoided whenever possible due to high risk of thrombosis and need to preserve vasculature for future hemodialysis access. 1, 2 If central access is required for repeated albumin infusions, administer prophylactic anticoagulation for as long as the line is in place. 1
Diuretics must be used with extreme caution and only when there is evidence of intravascular fluid overload (good peripheral perfusion, elevated blood pressure). 1, 4 Using diuretics in the presence of hypovolemia can worsen intravascular depletion and promote thrombosis—a major risk in nephrotic syndrome. 3, 4
Furosemide Safety Parameters
When administering furosemide with albumin: 2, 4
- Stop immediately if anuria develops 2, 4
- Administer IV infusions over 5-30 minutes to minimize ototoxicity 2, 4
- High-dose furosemide (>6 mg/kg/day) should not be given for longer than 1 week due to permanent hearing loss risk 2, 4
Common Pitfalls to Avoid
Do not use serum albumin levels as the sole indication for albumin infusion—this leads to unnecessary treatment and increased complications. 2, 4 The magnitude of proteinuria is determined by the underlying glomerular disease process, not by albumin therapy. 4
One older study suggested albumin administration may delay response to corticosteroid therapy and induce more frequent relapses in minimal change nephrotic syndrome, 6 though this finding has not been consistently replicated and should not preclude albumin use when true hypovolemia is present.
Monitoring Requirements
Essential monitoring parameters include: 2, 4
- Fluid status and urine output
- Electrolytes (particularly potassium and sodium)
- Blood pressure
- Kidney function (eGFR)
- Clinical signs of hypovolemia or fluid overload
Evidence from a 2022 systematic review showed that furosemide plus albumin increased urine volume more than furosemide alone (SMD 0.85,95% CI 0.33-1.38), though results for sodium excretion were inconclusive. 7 A 2011 randomized trial demonstrated that co-administration increased urine volume from 1707 mL to 2175 mL and improved GFR. 8