What is the recommended duration and dosage of albumin infusion for patients with liver disease, nephrotic syndrome, or severe burns?

Albumin Infusion Duration and Dosing

For liver disease, albumin infusion duration varies by indication: single-dose post-paracentesis, 3-day course for spontaneous bacterial peritonitis, or up to 14 days for hepatorenal syndrome with vasoconstrictors. 1, 2

Liver Disease - Specific Protocols

Large-Volume Paracentesis (>5L)

• Administer 6-8 g albumin per liter of ascites removed as a single infusion after paracentesis completion 1
• Use 20% or 25% albumin solution infused over 1-4 hours post-procedure 3
• For a typical 10-liter paracentesis requiring 80g albumin (320 mL of 25% solution), infuse at approximately 80-320 mL/hour 3
• This is a one-time administration, not continued beyond the procedure 1

Spontaneous Bacterial Peritonitis (SBP)

• Day 1: 1.5 g/kg within 6 hours of diagnosis (maximum 100g) 1, 2
• Day 3: 1.0 g/kg 1, 2
• For a 70 kg patient, this translates to 105g initially, then 70g on day 3, totaling 175g over 3 days 3
• This 3-day protocol is complete; no further albumin is indicated 1, 2
• Particularly beneficial when serum creatinine >1 mg/dL or bilirubin >4 mg/dL 2

Hepatorenal Syndrome (HRS-AKI)

• Day 1: 1 g/kg (maximum 100g) 1, 2
• Subsequent days: 20-40 g/day in combination with vasoconstrictors 1, 2
• Continue until creatinine returns to baseline, up to maximum 14 days 1, 2
• In rare cases with very high pretreatment creatinine, treatment may extend beyond 14 days 1
• Discontinue if creatinine remains at or above pretreatment level after 4 days at maximum tolerated vasoconstrictor doses 1

Critical Dosing Considerations

Maximum Safe Limits

• Never exceed 100g in the initial loading period 2
• Doses above 87.5-100g are associated with worse outcomes due to fluid overload 2
• The total dose should not exceed 2 g/kg body weight in absence of active bleeding 4

Infusion Rate Safety

• For hypoproteinemia, do not exceed 2 mL/minute to prevent circulatory embarrassment and pulmonary edema 4
• Rapid infusion (over 2 hours) caused pulmonary edema in 13% of stroke patients receiving high-dose albumin 3

Nephrotic Syndrome - NOT Recommended

Albumin administration is contraindicated in nephrotic syndrome as it is promptly excreted by the kidneys with no relief of chronic edema 4

• In minimal change nephrotic syndrome, albumin infusion significantly delays response to corticosteroids (73.4 vs 17.1 days, p<0.05) and increases relapse rates (68.8% vs 9.1%, p<0.01) 5
• Albumin should not be used for treatment of hypoalbuminemia alone 3, 6

Severe Burns - Extended Duration Protocol

Beyond 24 hours post-burn, albumin can be used to maintain plasma colloid osmotic pressure, with duration determined by ongoing protein losses 4, 6

• Target plasma albumin concentration of 2.5 ± 0.5 g/100 mL (plasma oncotic pressure 20 mmHg) 4
• Typical adult dose: 50-75g daily; children: 25g daily 4
• Duration is individualized based on protein loss from burned areas and urine 4
• Long-term albumin should not be considered nutritional support; initiate amino acid feeding concurrently 4

Solution Selection

25% vs 5% Albumin

• Use 25% albumin when minimizing volume is critical 3, 2
• 25% albumin produces plasma volume expansion equal to twice the infused volume 3
• 100 mL of 25% albumin (25g) requires less volume than 500 mL of 5% solution for the same dose 3
• Avoid 5% albumin when sodium restriction is important, as it increases sodium load five-fold compared to 25% solution 3

Monitoring for Adverse Effects

Common Complications

• Pulmonary edema from fluid overload (especially with rapid infusion or 25% solution in cirrhosis with sepsis) 1, 3
• Allergic and transfusion reactions 7
• Hemodilution requiring RBC transfusion 3
• Cardiovascular complications occur in up to 45% of patients receiving terlipressin with albumin 2

Key Monitoring Parameters

• Monitor central venous pressure when using continuous albumin therapy with vasoconstrictors 1, 2
• Watch for ischemic side effects (abdominal pain, peripheral ischemia) when combining with vasoconstrictors 1
• 58% of infused albumin is degraded, so higher doses do not proportionally increase serum levels 3