What is the use of albumin (human albumin) in patients with conditions such as liver disease, nephrotic syndrome, or malnutrition?

What is Albumin Used For?

Albumin is a human-derived blood product used primarily for specific liver disease complications—including large-volume paracentesis, spontaneous bacterial peritonitis, hepatorenal syndrome, and sepsis-induced hypotension in cirrhosis—and should NOT be used routinely for hypoalbuminemia correction, nutritional support, or general volume resuscitation in critically ill patients. 1, 2, 3

Established Evidence-Based Indications

Liver Disease Complications (Strong Recommendations)

Large-Volume Paracentesis:

• Administer albumin when removing >5L of ascitic fluid to prevent paracentesis-induced circulatory dysfunction 2, 4
• This indication has moderate certainty of evidence and is strongly recommended by the American Association for the Study of Liver Diseases 2
• The typical dose is 6-8 g of albumin per liter of ascitic fluid removed 5

Spontaneous Bacterial Peritonitis:

• Give 1.5 g/kg at diagnosis and 1.0 g/kg on day 3 2, 4
• This regimen reduces mortality and prevents hepatorenal syndrome with moderate certainty of evidence 2
• This is one of the most strongly supported indications for albumin use 1, 3

Hepatorenal Syndrome:

• Albumin is recommended as part of the treatment protocol for hepatorenal syndrome 1, 2
• Used in combination with vasoconstrictors for type 1 hepatorenal syndrome 6

Sepsis-Induced Hypotension in Cirrhosis:

• Use 5% albumin over normal saline in cirrhotic patients with sepsis-induced hypotension 2
• A 2024 RCT demonstrated higher 1-week survival with albumin (43.5% vs 38.3%, p=0.03) 2
• Albumin achieved higher rates of shock reversal compared to crystalloids 1

Hepatic Encephalopathy (Emerging Indication)

Acute Hepatic Encephalopathy:

• Consider albumin 1.5 g/kg on day 1 followed by 1.0 g/kg on day 3, combined with lactulose 2, 4
• Alternative regimen: 1.5 g/kg/day for up to 10 days with lactulose 4
• Evidence shows 75% complete resolution with albumin-lactulose versus 53% with lactulose alone (p=0.03) 2, 4
• Mortality was reduced (18% vs 32% at day 10, p=0.04) in one trial 1, 4
• However, certainty of evidence is low to very low, and guidelines show uncertainty about this indication 1, 2

Other Accepted Indications

Therapeutic Plasmapheresis:

• Albumin is indicated for fluid replacement during plasmapheresis with exchange of large volumes of plasma 7, 6

Cardiopulmonary Bypass:

• Used in pump priming to achieve a hematocrit of 20% and plasma albumin concentration of 2.5 g/100 mL 5

Neonatal Hemolytic Disease:

• Administer 1 g/kg body weight about 1 hour prior to exchange transfusion to bind free bilirubin and reduce kernicterus risk 5

What Albumin is NOT Used For (Strong Recommendations Against)

Do NOT use albumin for:

• Hypoalbuminemia correction alone - The American Thoracic Society explicitly recommends against this (adjusted OR 0.98,95% CI 0.71-1.33 for benefit) 1, 2, 3
• Nutritional support - Albumin is not a source of protein nutrition in malnutrition, malabsorption, or protein-losing enteropathies 5, 7
• Chronic nephrosis - Infused albumin is promptly excreted by the kidneys with no relief of chronic edema 5
• First-line volume replacement in critically ill patients - Balanced crystalloids (lactated Ringer's) are preferred for initial resuscitation 1, 2, 3
• Routine use in cardiovascular surgery, kidney replacement therapy, or neonatal/pediatric critical care 3

Physiologic Properties and Mechanism of Action

Oncotic Effects:

• Each 20 mL of 25% albumin (Plasbumin-25) supplies the oncotic equivalent of approximately 100 mL citrated plasma 5
• When administered intravenously, 20 mL of 25% albumin draws approximately 70 mL of fluid from extravascular tissues into circulation within 15 minutes 5
• This increases total blood volume and reduces hemoconcentration and whole blood viscosity 5

Non-Oncotic Properties:

• Albumin is produced exclusively by the liver and serves as a transport protein 1, 8
• It binds multiple substances including fatty acids, bilirubin, thyroid hormone, and drugs 1, 8
• Albumin has immunomodulatory, endothelial stabilization, and antioxidant effects 9, 8
• In advanced cirrhosis, albumin quality is decreased due to oxidative stress and proinflammatory states 9, 10

Critical Safety Considerations and Adverse Effects

Monitor Closely for Volume Overload:

• Patients with cirrhosis have increased capillary permeability and are at higher risk for pulmonary edema 1, 4
• More severe or life-threatening serious adverse events were reported in albumin-treated patients, primarily pulmonary edema 1, 4
• The ATTIRE trial showed significantly higher rates of pulmonary edema and fluid overload when targeting specific albumin levels 1

Immediately discontinue albumin if:

• Pulmonary edema develops 2
• Respiratory distress or declining oxygen saturation occurs 2

Other Potential Adverse Effects:

• Hypotension 3
• Hemodilution requiring RBC transfusion 3
• Anaphylaxis 3
• Allergic and transfusion reactions 9
• Peripheral gangrene from dilution of natural anticoagulants 3

Practical Algorithm for Albumin Administration

Step 1: Identify the Specific Indication

• Large-volume paracentesis (>5L removed) 2
• Spontaneous bacterial peritonitis (at diagnosis) 2
• Hepatorenal syndrome 1, 2
• Sepsis-induced hypotension in cirrhosis 2
• Consider for acute hepatic encephalopathy (with caution due to low certainty) 2, 4

Step 2: Assess Contraindications

• Evaluate cardiac function for risk of volume overload 2
• Assess pulmonary function and baseline respiratory status 2
• Avoid in patients with significant cardiac or pulmonary compromise 4

Step 3: Administer Appropriate Dose

• Large-volume paracentesis: 6-8 g per liter of ascitic fluid removed 5
• Spontaneous bacterial peritonitis: 1.5 g/kg at diagnosis, 1.0 g/kg on day 3 2, 4
• Acute hepatic encephalopathy: 1.5 g/kg day 1, then 1.0 g/kg day 3 (or 1.5 g/kg/day for up to 10 days) 2, 4
• Sepsis-induced hypotension: Use 5% albumin for resuscitation 2

Step 4: Monitor During and After Administration

• Use echocardiography to guide fluid management 2
• Watch for respiratory distress or declining oxygen saturation 2
• Monitor for signs of volume overload 2
• Discontinue immediately if pulmonary edema develops 2

Common Pitfalls to Avoid

Do not target specific serum albumin levels in hospitalized patients with decompensated cirrhosis - The ATTIRE trial showed no benefit and increased pulmonary complications when targeting albumin levels of 3 g/dL 1

Do not use albumin as a substitute for addressing underlying causes of hypoalbuminemia - Treatment should focus on the underlying disease process (sepsis, liver disease, nephrotic syndrome, malnutrition) rather than simply correcting the albumin level 3

Do not use albumin for chronic conditions without evidence-based indications - In chronic cirrhosis with malabsorption or protein-losing enteropathies, albumin infusion as a source of protein nutrition is not justified 5

Consider cost and availability - Albumin is expensive (approximately $130/25g) and should be reserved for evidence-based indications 3, 9