What are the treatment options for a patient with low albumin levels, possibly due to underlying liver or kidney disease, or malnutrition?

Treatment of Low Albumin

The primary treatment for low albumin is to identify and treat the underlying cause—not to administer intravenous albumin—with IV albumin reserved only for specific liver-related complications such as large-volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome. 1

Understanding Why Albumin is Low

Before treating, you must determine the mechanism:

• Inflammation is the most common driver of hypoalbuminemia, not malnutrition, as inflammatory cytokines directly downregulate hepatic albumin synthesis even when protein and caloric intake are adequate 1, 2
• Albumin functions as a negative acute-phase reactant, meaning it drops during any inflammatory state 1, 2
• Other mechanisms include decreased synthesis (liver disease), increased losses (nephrotic syndrome, protein-losing enteropathy), hemodilution from fluid overload, and true malnutrition 1, 3, 2

Critical pitfall: Assuming low albumin equals malnutrition when inflammation may be the primary cause 1, 3, 2

Diagnostic Workup

Systematically assess the following 1:

• Inflammatory markers (CRP, ferritin) to identify inflammation as the driver 1, 2
• Urine albumin-to-creatinine ratio to detect nephrotic-range proteinuria 1
• Liver function tests to assess synthetic function 1
• Hydration status as overhydration dilutes albumin concentration 1, 3
• Nutritional assessment using validated tools (Subjective Global Assessment, MUST, Mini Nutritional Assessment)—not albumin itself—to evaluate for true malnutrition 2

Primary Management Strategy

Treat the Underlying Condition

This is the cornerstone of management 1, 3:

For liver disease:

• Treat the underlying liver disease and its complications 1
• Provide nutrition targets of 1.2-1.3 g/kg/day protein and 30-35 kcal/kg/day 1
• Use albumin infusion ONLY for specific indications (see below) 1

For nephrotic syndrome:

• Reduce proteinuria with disease-specific immunosuppression 1
• Albumin infusion is generally NOT indicated except in congenital nephrotic syndrome with symptomatic hypovolemia 1

For chronic kidney disease/dialysis:

• Target albumin ≥4.0 g/dL 1
• Provide 1.2 g/kg/day protein 1
• Monitor dialysis adequacy (Kt/V) 1
• Address multiple risk factors including infections, dental disease, pain, and polypharmacy 4
• Monitor albumin at least every 4 months, more frequently during acute illness or declining trends 1, 2

For inflammation:

• Address the inflammatory source (infection, autoimmune disease, malignancy) 1, 2
• Recognize that albumin will not normalize until inflammation resolves 2

For malnutrition (when confirmed):

• Provide adequate protein (1.2-1.3 g/kg/day) and calories (30-35 kcal/kg/day) 1
• In dialysis patients, target normalized protein nitrogen appearance (nPNA) ≥0.9 g/kg/day 2
• Consider folate and vitamin B12 supplementation in dialysis patients to prevent deficiency 5

When IV Albumin IS Indicated

Albumin infusion is appropriate ONLY in these specific liver-related scenarios 1, 6, 7:

• Large-volume paracentesis 1, 6
• Spontaneous bacterial peritonitis at diagnosis 1, 6
• Hepatorenal syndrome 1, 6
• Acute kidney injury in cirrhosis 6

The amount and schedule require refinement to avoid volume overload complications 6, 7

When IV Albumin is NOT Indicated

Do not administer albumin to "correct the number" without addressing underlying pathology 1:

• NOT indicated for nephrotic syndrome (except congenital with symptomatic hypovolemia) 1
• NOT recommended for dialysis patients to prevent or treat intradialytic hypotension 3
• NOT indicated solely to increase serum albumin levels 3
• Targeting specific albumin levels with repeated infusions outside approved indications increases pulmonary edema risk 1, 7

Critical Pitfalls to Avoid

• Assuming hypoalbuminemia equals malnutrition when inflammation is often the primary driver 1, 3, 2
• Administering albumin to "correct the number" without addressing underlying pathology 1
• Ignoring fluid status as overhydration dilutes albumin concentration 1, 3
• Using albumin as a nutritional marker when it primarily reflects inflammation in acute illness 1, 2
• Failing to recognize non-nutritional factors affecting albumin such as age, comorbidities, metabolic acidosis, and protein losses 1, 2
• Failing to recognize that albumin synthesis can be suppressed by catabolic illness even with adequate protein intake 2

Clinical Significance

The stakes are high: each 0.1 g/dL decrease in serum albumin increases death risk by 6% in dialysis patients, increases hospitalization days by 5%, and increases technique failure risk by 5% in peritoneal dialysis patients 2. A meta-analysis found that a 1.0 g/dL decrease in albumin increased odds of morbidity by 89% and mortality by 137% 3.