What is the frequency of administering albumin (human albumin) intravenous (IV) therapy in patients with various medical conditions, such as liver disease, severe burns, or trauma?

Albumin IV Administration Frequency

The frequency of albumin administration depends entirely on the clinical indication: for spontaneous bacterial peritonitis (SBP), give two doses (1.5 g/kg within 6 hours of diagnosis, then 1.0 g/kg on day 3); for large-volume paracentesis, give a single dose after the procedure (8 g/L of ascites removed); and for hepatorenal syndrome, give daily doses (typically 20-40 g/day) in combination with vasoconstrictors for up to 20 days. 1

Evidence-Based Dosing Schedules by Indication

Spontaneous Bacterial Peritonitis (SBP)

• Administer 1.5 g/kg albumin within the first 6 hours of SBP diagnosis, followed by a second dose of 1.0 g/kg on day 3. 1
• This two-dose regimen reduces acute kidney injury from 33% to 10% and mortality from 29% to 10% compared to antibiotics alone. 1
• For a 70 kg patient, this translates to approximately 105 g initially, then 70 g on day 3 (total 175 g over 3 days). 2
• Patients with bilirubin >4 mg/dL or creatinine >1.0 mg/dL with BUN >30 mg/dL benefit most from this protocol. 1, 3

Large-Volume Paracentesis (>5 Liters)

• Give albumin as a single dose immediately after completing the paracentesis at 8 g per liter of ascites removed. 1, 4, 2
• For patients with acute-on-chronic liver failure (ACLF), use 6-8 g/L regardless of volume removed. 1
• Infuse over 1-4 hours post-procedure using 20% or 25% albumin solution. 2
• A typical 10-liter paracentesis requires 80 g albumin (320 mL of 25% solution). 2

Hepatorenal Syndrome (HRS-AKI)

• Administer 20-40 g albumin intravenously daily in combination with vasoconstrictors (such as terlipressin) for up to 20 days. 2
• Total treatment course may involve 200-400 g albumin over the full duration. 2
• This is used as part of a combination therapy protocol, not as monotherapy. 1, 2

Paracentesis <5 Liters

• Albumin is NOT routinely indicated for modest-volume paracentesis (<5 liters). 5
• The evidence supporting albumin use is weak for smaller volume procedures. 5

Critical Timing Considerations

Why Timing Matters

• Albumin has a transient effect lasting hours to days, not weeks, which is why repeat dosing is required for different indications. 4
• The half-life and volume expansion effects are temporary, necessitating the specific timing protocols outlined above. 4
• For SBP, the day 3 dose is given because the initial dose effect has waned by that time. 4

Long-Term Administration (Investigational)

• Weekly outpatient albumin infusions have been studied in patients with refractory ascites, showing potential benefits only with ongoing administration. 4
• The ANSWER trial used weekly dosing and showed reduced 18-month mortality, but this was an unblinded study. 1
• Current guidelines do NOT recommend routine weekly or chronic albumin administration for uncomplicated ascites. 1

When NOT to Give Albumin

Contraindicated Uses

• Do NOT use albumin for uncomplicated ascites without specific complications - standard therapy is sodium restriction plus diuretics (spironolactone ± furosemide). 1
• Do NOT use albumin for infections other than SBP - it does not reduce AKI or mortality and increases pulmonary edema risk. 1
• Do NOT use albumin to correct hypoalbuminemia alone without specific acute complications like SBP or large-volume paracentesis. 4, 2, 6
• Do NOT use albumin for routine volume replacement in critically ill patients - crystalloids are first-line and equally effective. 4, 2

Specific Contraindications by Condition

• Chronic nephrosis: infused albumin is promptly excreted with no clinical benefit. 6
• Chronic cirrhosis without acute complications: not justified as protein nutrition source. 6
• Cardiovascular surgery: routine use not recommended. 4, 2
• Intradialytic hypotension: not recommended as routine therapy due to high cost ($20,000 annually per patient) without definitive superiority. 4

Safety Considerations and Dose Limits

Maximum Dosing Thresholds

• Doses exceeding 87.5 g (>4 × 100 mL of 20% albumin) may be associated with worse outcomes due to fluid overload in cirrhosis patients. 4
• The total dose should not exceed approximately 2 g/kg body weight in the absence of active bleeding. 6
• Close monitoring is mandatory during administration, particularly for signs of circulatory overload. 4, 6

Documented Adverse Effects

• Fluid overload and pulmonary edema (most common, especially with rapid infusion or high doses). 1, 4, 2
• Hypotension and tachycardia. 1, 2
• Hemodilution requiring RBC transfusion. 4, 2
• Anaphylaxis and allergic reactions. 4, 2, 7
• Peripheral gangrene from dilution of natural anticoagulants. 4, 2

Infusion Rate Guidelines

• For hypoproteinemia with normal blood volume, do not exceed 2 mL per minute to avoid circulatory embarrassment and pulmonary edema. 6
• For post-paracentesis administration, infuse over 1-4 hours. 2
• Rapid infusion (over 2 hours) in stroke trials resulted in 13% pulmonary edema rate, confirming the need for caution. 2

Practical Algorithm for Clinical Decision-Making

Step 1: Identify the Indication

• Is this SBP? → Two-dose protocol (day 1 and day 3)
• Is this large-volume paracentesis (>5L)? → Single dose post-procedure
• Is this hepatorenal syndrome? → Daily dosing with vasoconstrictors for up to 20 days
• Is this uncomplicated ascites or hypoalbuminemia alone? → Do NOT give albumin

Step 2: Calculate the Dose

• SBP: 1.5 g/kg (day 1), then 1.0 g/kg (day 3) based on estimated dry weight 1
• Large-volume paracentesis: 8 g per liter removed (6-8 g/L for ACLF) 1, 4
• HRS-AKI: 20-40 g daily with vasoconstrictors 2

Step 3: Select the Concentration

• Use 25% albumin when minimizing volume is critical (requires less volume: 100 mL for 25 g vs 500 mL for 5% solution). 2
• Avoid 5% albumin when sodium restriction is important (increases sodium load five-fold compared to 25% solution). 2
• Both 5% and 25% solutions are isotonic and safe for IV administration. 2

Step 4: Monitor for Complications

• Watch for fluid overload, especially in patients with elevated or rising creatinine. 4
• Monitor for pulmonary edema, particularly with doses >87.5 g or rapid infusion. 4, 2
• Assess hemodynamic response and adjust accordingly. 6

Common Pitfalls to Avoid

• Do not give albumin repeatedly for chronic hypoalbuminemia - 58% of infused albumin is degraded, and chronic supplementation is expensive without proven clinical benefit. 2, 6, 7
• Do not use albumin as a protein nutrition source - it is not justified for malnutrition, malabsorption, or protein-losing enteropathies. 6
• Do not assume "more is better" - higher doses do not proportionally increase serum levels due to increased degradation rates. 2
• Do not forget that albumin effect is temporary - the volume expansion and oncotic effects last only hours to days, which is why specific timing protocols exist. 4