Why is albumin administered during a hemodialysis (HD) session to patients with end-stage renal disease (ESRD) and hypotension or hypoalbuminemia?

Albumin Administration During Hemodialysis

Albumin is generally NOT recommended for routine use during hemodialysis sessions, as current evidence does not support superiority over less costly alternatives like saline for preventing or treating intradialytic hypotension in most patients. 1

Primary Rationale Against Routine Albumin Use

The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommends against albumin for intradialytic hypotension due to:

• Lack of mortality or morbidity benefit compared to crystalloids in most dialysis patients 1
• Prohibitive cost: approximately $20,000 per patient annually for thrice-weekly albumin administration 1
• No improvement in ultrafiltration in most studies comparing albumin to saline 1, 2

A Cochrane systematic review found that 5% albumin was not superior to normal saline for treating symptomatic hypotension in maintenance hemodialysis patients with previous intradialytic hypotension history 2. Given albumin's cost and relative rarity compared to saline, saline should be the first-line therapy 2.

When Albumin May Be Considered (Limited Evidence)

Specific High-Risk Scenario

Albumin administration may have benefit in a narrow subset of hospitalized hemodialysis patients who meet ALL of the following criteria:

• Serum albumin <30 g/L (3.0 g/dL) 3
• Recurrent intradialytic hypotension despite standard interventions 3
• Hospitalized/acutely ill status 3

In this specific population, one 2021 randomized crossover trial (N=65) found that 25% albumin (100 mL at dialysis initiation) compared to saline resulted in:

• Reduced hypotension episodes (7% vs 15%, p=0.002) 3
• Higher lowest intradialytic systolic BP (90 vs 83 mmHg, p=0.035) 3
• Improved ultrafiltration rate (p=0.011) 3

However, this represents the single most recent high-quality study supporting albumin use, and the guideline authors still recommend against routine use given cost considerations 1.

Preferred Alternative Strategies

Before considering albumin, the following evidence-based interventions should be implemented:

• Higher dialysate calcium concentration 1
• Lower dialysate temperature 1
• Individualized ultrafiltration rates (avoid aggressive fluid removal) 1
• Midodrine (oral vasopressor) alone or combined with above strategies 1
• Saline boluses as first-line volume expansion 2
• Mannitol as second-line osmotic agent 4

A protocol-based approach using stepwise saline → mannitol → albumin (only if first two fail) successfully reversed hypotension in 93% of cases while using albumin in only 6% of treatments 4.

Critical Pitfalls to Avoid

• Do not assume hypoalbuminemia requires albumin replacement: Low serum albumin in dialysis patients is primarily a marker of inflammation and mortality risk, not a direct indication for albumin infusion 5, 6
• Do not use albumin to "correct" low albumin levels: The underlying causes (inflammation, malnutrition, protein losses) must be addressed through adequate dialysis, nutrition (1.2-1.3 g/kg/day protein), and treating catabolic illness 5
• Recognize fluid overload risk: Albumin can precipitate pulmonary edema, particularly in patients with compromised cardiac function 7

Clinical Algorithm for Decision-Making

1. Intradialytic hypotension occurs → Start with saline bolus (100-250 mL) 4, 2
2. If hypotension persists → Add mannitol (12.5-25 g) 4
3. If both fail AND patient has serum albumin <30 g/L → Consider 100 mL of 25% albumin 3
4. If serum albumin ≥30 g/L → Do NOT use albumin; reassess dialysis prescription (lower ultrafiltration rate, adjust dialysate temperature/calcium) 1

The evidence strongly favors cost-effective alternatives over routine albumin use, with albumin reserved only for exceptional cases where standard measures fail in severely hypoalbuminemic hospitalized patients 1, 3.