What are the indications for albumin administration in patients with hypoalbuminemia due to conditions such as liver disease, nephrotic syndrome, or major surgery?

Indications for Albumin Administration

Albumin should NOT be used to correct hypoalbuminemia alone—the primary evidence-based indications are specific liver disease complications (spontaneous bacterial peritonitis, large-volume paracentesis >5L, hepatorenal syndrome) and as second-line therapy for fluid resuscitation when crystalloids fail in septic or hypovolemic shock. 1, 2

Strong Evidence-Based Indications (Use Albumin)

Liver Disease Complications

Spontaneous Bacterial Peritonitis (SBP)

• Administer 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 2, 3
• Greatest benefit occurs in patients with serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL 3
• This reduces acute kidney injury and mortality 2, 3

Large-Volume Paracentesis

• Give 8 g albumin per liter of ascitic fluid removed when >5L is drained 2, 3
• Administer after the procedure is completed 2
• For patients with acute-on-chronic liver failure, use 6-8 g/L regardless of volume removed 2, 3
• Prevents paracentesis-induced circulatory dysfunction 2, 4

Hepatorenal Syndrome (HRS-AKI)

• Day 1: 1 g/kg albumin 3
• Subsequent days: 20-40 g daily along with vasoactive agents (e.g., terlipressin) 3
• Continue until serum creatinine returns to within 0.3 mg/dL of baseline for 2 consecutive days, or maximum 14 days 3
• For Stage 2-3 AKI in cirrhosis with ascites: withdraw diuretics and give 1 g/kg albumin daily for 2 consecutive days 3

Plasmapheresis

• Fluid replacement during therapeutic plasma exchange with large volumes 5, 6

Second-Line/Adjunctive Indications (Consider After Crystalloids)

Hypovolemic and Septic Shock

• Use only when crystalloids are ineffective or contraindicated 5, 7
• Not for first-line volume replacement 1, 2, 4
• The FDA label indicates hyperoncotic albumin (25%) expands plasma volume 3-4 times the administered volume in normally hydrated patients 8
• Total dose should not exceed 2 g/kg body weight in absence of active bleeding 8

Major Surgery with Significant Albumin Loss

• Patients can lose over half their circulating albumin during major surgery 8
• Consider albumin when oncotic deficit is present 8
• Preoperative albumin <3.0 g/dL increases risk of surgical site infections and poor wound healing 3

Burns (Beyond 24 Hours)

• During first 24 hours: use large volumes of crystalloids 8
• After 24 hours: 25% albumin may be used to maintain plasma colloid osmotic pressure 8

ARDS with Hypoproteinemia and Fluid Overload

• Use 25% albumin together with a diuretic when clinical signs show hypoproteinemia with fluid volume overload 8

Cardiopulmonary Bypass

• Adjust albumin and crystalloid pump prime to achieve plasma albumin concentration of 2.5 g/dL 8

Explicit Contraindications (DO NOT Use Albumin)

General Critical Care

• NOT for routine volume replacement in critically ill adults, neonates, or pediatric patients 1, 2, 4
• NOT for correcting hypoalbuminemia alone without specific complications 1, 2, 3, 8
• NOT for cardiovascular surgery (routine use) 1, 2
• NOT for intradialytic hypotension (routine therapy) 1, 2

Liver Disease

• NOT for uncomplicated ascites in cirrhosis 2
• NOT for extraperitoneal infections in cirrhosis 1, 2
• NOT for other infections in cirrhosis beyond SBP—increases pulmonary edema without benefit 3

Chronic Conditions

• NOT for chronic nephrosis—albumin is promptly excreted with no relief of edema 8
• NOT for chronic cirrhosis, malabsorption, protein-losing enteropathies, pancreatic insufficiency, or undernutrition as nutritional support 8, 7

Nephrotic Syndrome

• NOT for routine treatment—only consider in acute nephrosis unresponsive to cyclophosphamide/steroids, using 100 mL of 25% albumin daily for 7-10 days with loop diuretic 8

Critical Safety Considerations

Fluid Overload Risk

• Fluid overload and pulmonary edema are documented complications, particularly in cirrhotic patients 2, 3
• Doses exceeding 87.5 g (>4×100 mL of 20% albumin) may worsen outcomes in cirrhosis patients 2
• Monitor carefully during administration, especially in patients with rising serum creatinine 2

Other Complications

• Hypotension 2, 4
• Hemodilution requiring RBC transfusion 2, 4
• Anaphylaxis 2, 4
• Peripheral gangrene from dilution of natural anticoagulants 2, 4

Cost Considerations

• Albumin costs approximately $130 per 25g, substantially more expensive than crystalloids 2, 4
• For intradialytic hypotension, annual cost is approximately $20,000 per patient without definitive superiority over alternatives 2

Common Pitfalls to Avoid

Pitfall #1: Using albumin to "correct" low albumin levels

• Hypoalbuminemia is a marker of inflammation and disease severity, not a treatment target 3, 7
• Focus on treating the underlying cause (inflammation, malnutrition, protein loss) 4, 3

Pitfall #2: Assuming hypoalbuminemia equals malnutrition

• Inflammatory cytokines directly downregulate hepatic albumin synthesis even with adequate nutrition 3
• Measure C-reactive protein to distinguish inflammation-driven hypoalbuminemia from pure malnutrition 3

Pitfall #3: Using albumin for volume replacement when crystalloids would suffice

• Crystalloids are equally effective and far less expensive in most shock states 2, 5, 9
• Reserve albumin for specific indications or when crystalloids fail 5, 7

Pitfall #4: Rapid or excessive administration in cirrhosis

• Monitor for fluid overload, especially with doses >87.5 g 2
• Administer at appropriate intervals (e.g., SBP dosing on day 1 and day 3) 2, 3

Proper Management of Hypoalbuminemia

Instead of albumin infusion, address the underlying cause:

• Ensure adequate protein intake: 1.2-1.3 g/kg/day 3
• Provide sufficient calories: 30-35 kcal/kg/day 3
• Treat active inflammation 3
• Correct fluid overload (hemodilution decreases albumin concentration) 3
• Minimize external protein losses (treat proteinuria, reduce dialysate losses) 3