Is albumin infusion effective in raising blood pressure in patients with end-stage renal disease experiencing hypotension during dialysis?

Albumin Infusion for Intradialytic Hypotension

Albumin infusion during dialysis is not recommended for raising blood pressure or improving ultrafiltration in most patients with intradialytic hypotension, as it provides no mortality or morbidity benefit over crystalloids and costs approximately $20,000 per patient annually for thrice-weekly administration. 1, 2

Primary Recommendation

The International Collaboration for Transfusion Medicine Guidelines (2024) explicitly recommends against albumin for intradialytic hypotension prevention or treatment, citing very low certainty of evidence. 1 A Cochrane systematic review found no difference in achieving target ultrafiltration or other clinical outcomes when comparing albumin to normal saline. 1

Evidence Supporting Limited Use

One exception exists: A 2021 randomized crossover trial in 65 hospitalized patients with serum albumin <30 g/L (3.0 g/dL) demonstrated that 25% albumin improved hypotension rates (15% with saline vs. 7% with albumin, p=0.002), lowest intradialytic systolic BP (83 mmHg saline vs. 90 mmHg albumin, p=0.035), and ultrafiltration rates compared to saline. 1, 3 However, this benefit was limited to hypoalbuminemic hospitalized patients and did not demonstrate improvements in mortality or long-term outcomes. 3

Preferred Alternative Strategies (In Order of Implementation)

Before considering albumin, implement these evidence-based interventions:

1. Dialysate modifications:

   • Increase dialysate calcium concentration 1, 2
   • Lower dialysate temperature to 34-35°C 1, 4, 2
   • Use bicarbonate-containing dialysate instead of acetate 4

2. Ultrafiltration adjustments:

   • Individualize ultrafiltration rates to avoid aggressive fluid removal 1, 2
   • Consider longer, slower dialysis sessions 5

3. Midodrine (oral vasopressor):

   • Administer 5-10 mg orally 30 minutes before dialysis initiation 1, 4, 2, 6
   • Meta-analysis shows midodrine improves nadir systolic BP by 13 mmHg (95% CI: 9-18 mmHg, p<0.0001) 1
   • Proven effective and safe over 8 months of follow-up 6
   • Critical advantage: Costs substantially less than albumin's $20,000 annual expense 1, 2

When Albumin Might Be Considered

Only in highly selected circumstances:

• Hospitalized patients with serum albumin <30 g/L (3.0 g/dL) experiencing recurrent symptomatic intradialytic hypotension despite implementation of all alternative strategies 1, 3
• Dose: 100 mL of 25% albumin at dialysis initiation 3
• Duration: Short-term use only until clinical stabilization; not for chronic maintenance therapy 1, 2

Critical Pitfalls to Avoid

1. Do not use albumin to "correct" low serum albumin levels - Low albumin in dialysis patients primarily reflects inflammation and mortality risk, not a direct indication for albumin infusion. 2 Address underlying causes (inflammation, malnutrition, protein losses) through adequate dialysis, nutrition optimization, and treating catabolic illness. 2

2. Recognize fluid overload risk - Albumin can precipitate pulmonary edema, particularly in patients with compromised cardiac function. 2 This risk increases in patients with pre-existing heart failure or volume overload. 5

3. Avoid chronic albumin therapy - The annual cost of thrice-weekly albumin administration ($20,000 per patient) is prohibitive without evidence of improved patient-important outcomes. 1, 2

4. Monitor for supine hypertension with midodrine - When using midodrine as the preferred alternative, avoid doses within several hours of bedtime and monitor for bradycardia, particularly with concurrent beta-blockers or calcium channel blockers. 4

Clinical Algorithm for Intradialytic Hypotension Management

Step 1: Optimize dialysate parameters (higher calcium, lower temperature 34-35°C, bicarbonate-based) 1, 4, 2

Step 2: Individualize ultrafiltration rate to patient tolerance; consider longer dialysis sessions 1

Step 3: Initiate midodrine 5-10 mg orally 30 minutes pre-dialysis 1, 4, 2, 6

Step 4: If Steps 1-3 fail AND patient is hospitalized with albumin <30 g/L, consider short-term 25% albumin 100 mL at dialysis start 1, 3

Step 5: If hypotension persists, evaluate for cardiac dysfunction, autonomic insufficiency, or medication effects requiring alternative management 5, 7