At what level of hypoalbuminemia is albumin infusion indicated, particularly in patients with cirrhosis or undergoing large-volume paracentesis?

Albumin Infusion Indications Based on Clinical Context, Not Absolute Albumin Level

Albumin infusion is not indicated based on a specific serum albumin threshold alone—instead, it is indicated for specific clinical scenarios in cirrhosis, particularly large-volume paracentesis >5 liters and spontaneous bacterial peritonitis, regardless of the baseline albumin level. 1

Key Principle: Indication-Based, Not Level-Based

The decision to administer albumin should be driven by the clinical scenario rather than attempting to "correct" a low albumin number:

• Albumin infusion is NOT recommended for treatment of hypoalbuminemia alone, even in cirrhotic patients, as serum albumin concentration does not reflect albumin function in liver disease 2
• The conventional definition of hypoalbuminemia (albumin <3.5 g/dL) is problematic in cirrhosis because dye-binding measurement methods overestimate true albumin levels by approximately 0.2 g/dL compared to immunoassay 3
• In chronic liver disease with hypoalbuminemia, infused albumin does not provide sustained benefit when given solely to raise the albumin number 4

Evidence-Based Indications for Albumin in Cirrhosis

Large-Volume Paracentesis (Strong Indication)

For paracentesis >5 liters, albumin is indicated at 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction, administered after the procedure is completed 1, 5, 2:

• This translates to 100 mL of 20% albumin per 3 liters removed 2
• For a typical 10-liter paracentesis, this equals 80 grams total albumin 2
• The albumin prevents circulatory dysfunction that occurs in up to 80% of patients without volume expansion, reducing this to 18.5% with albumin 5

For paracentesis <5 liters, albumin is generally not required unless the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 5, 2

Spontaneous Bacterial Peritonitis (Strong Indication)

Albumin dosing for SBP: 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 5, 2:

• For a 70 kg patient, this equals 105 g initially, then 70 g on day 3 (175 g total) 2
• This regimen reduces renal dysfunction risk by 72% and mortality by 47% 2
• This indication applies regardless of baseline serum albumin level 2

Hepatorenal Syndrome (Conditional Indication)

Albumin 10-20 grams IV daily for up to 20 days in combination with vasoconstrictors (such as terlipressin), totaling 200-400 grams over the treatment course 2:

• Albumin is always used with vasoconstrictors, not as monotherapy 2

Acute Kidney Injury in Cirrhosis (Emerging Indication)

• Albumin may be beneficial even before etiological diagnosis of AKI in cirrhotic patients 6
• Evidence is still evolving for this indication 7, 6

Clinical Scenarios Where Albumin is NOT Indicated

Do not administer albumin in the following situations, even with documented hypoalbuminemia 1, 4:

• Chronic nephrosis: Infused albumin is promptly excreted with no relief of edema 4
• Chronic cirrhosis with hypoalbuminemia alone: Not justified as protein nutrition source 4
• Critically ill patients for volume replacement: No mortality benefit over crystalloids 1
• ARDS or thermal injuries: Not suggested for volume replacement or to increase albumin level 1
• Routine critical care, dialysis, or cardiovascular surgery: Not recommended 1
• Preterm neonates: Not suggested for volume replacement or respiratory function 1

Common Pitfalls to Avoid

Do not reflexively order albumin infusions based on laboratory values alone—this represents outdated practice not supported by current evidence 2, 4:

• A serum albumin of 2.5 g/dL in a stable cirrhotic outpatient does NOT warrant albumin infusion 4
• Albumin measurement by bromcresol green method overestimates true levels in cirrhosis, leading to inappropriate clinical decisions 3
• 58% of infused albumin is rapidly degraded, meaning repeated infusions for "correction" of hypoalbuminemia are futile 2

Recognize that albumin quality, not just quantity, is impaired in cirrhosis—oxidized albumin and glycoalbumin increase with disease progression, further limiting the utility of targeting a specific albumin number 7, 3

Practical Algorithm for Decision-Making

1. Is the patient undergoing large-volume paracentesis >5 L? → Yes: Give 8 g albumin/L removed 1, 5
2. Does the patient have spontaneous bacterial peritonitis? → Yes: Give 1.5 g/kg then 1.0 g/kg on day 3 5, 2
3. Does the patient have hepatorenal syndrome? → Yes: Give 10-20 g daily with vasoconstrictors 2
4. Is the indication simply "low albumin"? → No albumin indicated 2, 4