What is the recommended dosage and administration rate for human albumin drip in a patient, considering factors such as age, weight, and medical history, including conditions like liver disease?

Human Albumin Administration: Dosing and Infusion Guidelines

Primary Recommendation for Albumin Dosing

For large-volume paracentesis (>5L), administer 6-8 grams of albumin per liter of ascites removed using 20% or 25% albumin solution, infused after the paracentesis is completed over 1-4 hours. 1

Specific Dosing by Clinical Indication

Large-Volume Paracentesis (>5L)

• Standard dose: 6-8 g albumin per liter of ascites removed 1
• Example calculation: For 10L paracentesis = 60-80 grams total albumin 2
• Timing: Administer after paracentesis completion 1, 2
• Infusion rate: Over 1-4 hours post-procedure (approximately 80-320 mL/hour for typical volumes) 2
• Solution: Use 20% or 25% albumin 1, 2

Critical consideration: Risk of post-paracentesis circulatory dysfunction (PPCD) increases with >8L fluid removal in a single session 1. Some evidence suggests higher doses (9.0 ± 2.5 g/L) may preserve renal function better when limiting paracentesis to <8L per session 1.

Spontaneous Bacterial Peritonitis (SBP)

• Day 1: 1.5 g/kg body weight within 6 hours of diagnosis 1, 2, 3
• Day 3: 1.0 g/kg body weight 1, 2, 3
• Example for 70 kg patient: 105g initially, then 70g on day 3 (total 175g over 3 days) 2
• Patient selection: Highest benefit in patients with serum bilirubin >4 mg/dL and/or baseline creatinine >1.0 mg/dL with BUN >30 mg/dL 1
• Outcome data: Reduces AKI from 33% to 10% and mortality from 29% to 10% 1, 2

Important caveat: Lower doses (10g/day for 3 days) have shown benefit in small studies, but standard dosing remains 1.5 g/kg then 1.0 g/kg 1.

Hepatorenal Syndrome (HRS-AKI)

• Dose: 10-20 grams IV daily for up to 20 days 2
• Total course: 200-400 grams over treatment period 2
• Administration: Always in combination with vasoconstrictors (e.g., terlipressin) 1, 2

Muscle Cramps in Cirrhosis

• Dose: 20-40 grams per week 1
• Alternative: Consider baclofen 10 mg/day, increasing weekly by 10 mg/day up to 30 mg/day 1

Refractory Ascites (Long-term Management)

• Dose studied: 20 grams twice weekly 1
• Current recommendation: Insufficient data to recommend routine long-term use outside large-volume paracentesis 1
• Evidence: One cohort study showed reduced hospitalizations and mortality with 20g twice weekly, but randomized trials needed 1

Solution Selection and Preparation

Choosing Between 5% and 25% Albumin

• 25% albumin preferred when:

  • Minimizing volume is critical 2
  • Sodium restriction required (5% solution increases sodium load five-fold) 2, 3
  • Volume expansion needed (produces plasma expansion equal to twice infused volume) 3

• Volume comparison: 25g albumin = 100 mL of 25% solution vs 500 mL of 5% solution 2

Administration Technique

• Dilution options: May be given undiluted or diluted in 0.9% sodium chloride or 5% dextrose 4
• Sodium restriction: Use undiluted or dilute only in 5% dextrose (sodium-free) 4
• Needle size: Use only 16-gauge needles or dispensing pins for 20 mL vials and larger 4
• Stopper penetration: Insert perpendicular within raised ring area 4

Infusion Rate Guidelines

Standard Rates by Condition

• Hypoproteinemia: Maximum 2 mL/minute to prevent circulatory overload and pulmonary edema 4
• Post-paracentesis: 80-320 mL/hour over 1-4 hours 2
• SBP: Infuse 1.5 g/kg dose within 6 hours of diagnosis 1, 3

Critical safety warning: Rapid infusion (e.g., 2.05 g/kg over 2 hours in stroke studies) caused pulmonary edema in 13% of patients 2. Slower rates are essential in cirrhosis.

Patient-Specific Dosing Considerations

Weight-Based Calculations

• Use estimated dry weight for cirrhotic patients, though this can be challenging to calculate accurately 2
• Maximum total dose: Should not exceed 2 g/kg body weight in absence of active bleeding 4

Patients with ACLF

• Paracentesis dosing: 6-8 g/L regardless of volume removed 1
• Caution: Doses exceeding 87.5g may worsen outcomes due to fluid overload 3

Monitoring During Administration

• Mandatory monitoring: Watch for circulatory overload (FDA requirement) 3
• Hemodynamic response: Monitor continuously, especially in patients with normal blood volumes 4
• Volume status: Particularly critical in patients with renal dysfunction who are often fluid overloaded 4

When NOT to Use Albumin

Contraindicated or Not Recommended

• Uncomplicated ascites: No benefit for routine diuretic-responsive ascites 1
• Hypoalbuminemia alone: Not indicated for correcting low albumin without specific complications 1, 2, 3
• Infections other than SBP: Three RCTs and meta-analysis show no benefit and increased pulmonary edema risk 1
• Chronic nephrosis: Albumin promptly excreted with no benefit 4
• Nutritional supplementation: Not justified in malabsorption, protein-losing enteropathies, or malnutrition 4
• First-line volume resuscitation: Crystalloids equally effective and far less expensive in most critically ill patients 2, 3

Adverse Effects and Complications

Common Complications

• Fluid overload and pulmonary edema: Most significant risk, especially with higher doses or rapid infusion 1, 2, 3
• Hypotension/tachycardia 1, 3
• Hemodilution requiring RBC transfusion 2, 3
• Anaphylaxis 2, 3
• Peripheral gangrene: From dilution of natural anticoagulants 2, 3

Risk Mitigation

• Avoid doses >87.5g in cirrhosis due to fluid overload risk 3
• Infuse slowly (≤2 mL/min) in hypoproteinemic patients with normal blood volumes 4
• Monitor closely in patients with cardiovascular disease or renal dysfunction 4

Pharmacokinetic Considerations

Duration of Effect

• Effect duration: Hours to days, not weeks 3
• Albumin degradation: 58% of infused albumin is degraded; 15% increase in serum albumin leads to 39% increase in degradation 2, 3
• Clinical implication: Repeated dosing required for sustained benefit (e.g., day 1 and day 3 for SBP) 2, 3

Expected Serum Albumin Increase

• 25g albumin (100 mL of 25%): Increases serum albumin by approximately 0.2-0.3 g/dL 3
• Target for burns/hypoproteinemia: Maintain plasma albumin ~2.5 ± 0.5 g/dL 4

Cost Considerations

Albumin costs approximately $130 per 25g, making it substantially more expensive than crystalloids 2, 3. This supports restricting use to well-defined, evidence-based indications where benefit is proven 2, 3.

Key Clinical Pitfalls to Avoid

1. Do not use albumin for chronic hypoalbuminemia without specific cirrhosis complications 1, 2, 3
2. Do not exceed 8L paracentesis in single session without careful consideration of PPCD risk 1
3. Do not infuse rapidly in patients with normal blood volumes (risk of pulmonary edema) 2, 4
4. Do not use for infections other than SBP (increased harm without benefit) 1
5. Do not forget sodium restriction when using 5% albumin solution 2, 4