Indications for Albumin Infusion
Albumin infusion is NOT recommended for correcting hypoalbuminemia or volume replacement in most critically ill patients, with specific exceptions limited to cirrhosis-related complications (large-volume paracentesis >5L and spontaneous bacterial peritonitis), hepatorenal syndrome, and emergency hypovolemic shock. 1
When Albumin Should NOT Be Used
The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommends against albumin in the following scenarios:
- Critically ill patients without thermal injuries or ARDS: Albumin is not suggested for first-line volume replacement or to increase serum albumin levels (conditional recommendation, moderate certainty) 1
- Critically ill patients with thermal injuries or ARDS: Albumin is not recommended for volume replacement or albumin correction 2
- Conjunction with diuretics: Albumin infusion is not recommended for removal of extravascular fluid 2
- Preterm neonates: Not recommended for respiratory distress with low serum albumin 2
- Intradialytic hypotension: Not recommended for prevention or treatment in kidney replacement therapy patients 2
- Pediatric cardiovascular surgery: Not recommended 2
- General hypoalbuminemia: The American College of Physicians recommends treating the underlying cause rather than the low albumin level itself 2
Critical Evidence Against Routine Use
Multiple studies demonstrate no clinical benefit from albumin therapy in hypoalbuminemic critically ill patients, showing no improvement in mortality (39% vs 27%), major complications, hospital length of stay, ICU stay, or ventilator dependence despite significant albumin elevation 3. Albumin infusion or nutritional supplementation does not improve survival in acute surgical patients with hypoalbuminemia 4, 5.
Specific Indications Where Albumin IS Recommended
Cirrhosis-Related Complications
Large-volume paracentesis (>5L): Administer 8 grams of albumin per liter of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction 2, 6
- For acute-on-chronic liver failure: Use 6-8 g/L regardless of volume removed 2
Spontaneous bacterial peritonitis: Give 1.5 g/kg body weight on day 1 and 1.0 g/kg on day 3, which reduces acute kidney injury and mortality 2
- Patients with serum bilirubin >4 mg/dL or baseline creatinine >1.0 mg/dL benefit most 2
Hepatorenal syndrome-AKI: Administer 1 g/kg albumin on day 1 followed by 20-40 g daily with vasoactive agents, continuing until serum creatinine returns to within 0.3 mg/dL of baseline for 2 consecutive days or maximum 14 days 2
Stage 2-3 acute kidney injury in cirrhosis with ascites: Withdraw diuretics immediately and administer 1 g/kg body weight albumin daily for 2 consecutive days 2
Emergency Hypovolemic Shock
- Plasbumin-25 (hyperoncotic albumin): FDA-approved for emergency treatment of hypovolemic shock, expanding plasma volume by 3-4 times the administered volume by withdrawing fluid from interstitial spaces 6
Other FDA-Approved Indications
- Burn therapy beyond 24 hours: Maintain plasma colloid osmotic pressure, targeting plasma albumin concentration of 2.5 ± 0.5 g/100 mL 6
- Adult respiratory distress syndrome (ARDS): When clinical signs show hypoproteinemia with fluid volume overload, Plasbumin-25 with diuretic may play a role 6
- Cardiopulmonary bypass: Adjust albumin and crystalloid pump prime to achieve plasma albumin concentration of 2.5 g/100 mL 6
- Neonatal hemolytic disease: 1 g/kg body weight given 1 hour prior to exchange transfusion to bind free bilirubin 6
- Congenital nephrotic syndrome: Daily albumin infusions of 1-4 g/kg based on clinical indicators of hypovolemia 2
- Sequestration of protein-rich fluids: In acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis 6
Administration Guidelines
- Rate of administration: Should not exceed 2 mL per minute in hypoproteinemic patients with normal blood volumes to avoid circulatory embarrassment and pulmonary edema 6
- Usual adult dose: 50-75 g daily for hypoproteinemia; children 25 g daily 6
- Dilution options: May be administered undiluted or diluted in 0.9% sodium chloride or 5% dextrose in water 6
Important Adverse Effects and Monitoring
Albumin carries significant risks that must be weighed against potential benefits:
- Fluid overload and pulmonary edema: Especially in patients with compromised cardiac or pulmonary function 7
- Hypotension and tachycardia: Can occur paradoxically despite use for hypovolemia 7
- Hemodilution: May require RBC transfusion 1, 7
- Anaphylaxis: Including rash, pruritus, rigors, and pyrexia 7
- Peripheral gangrene: From dilution of natural anticoagulants 1
- Cost: Approximately $130 per 25 g, making it an expensive intervention with limited proven benefit 1
Monitoring Recommendations
- Watch for respiratory distress, pulmonary rales, and peripheral edema indicating fluid overload 7
- Monitor for hypotension and tachycardia during infusion 7
- Be vigilant for allergic reactions including skin changes, fever, and rigors 7
Primary Treatment Approach for Hypoalbuminemia
The cornerstone of management is treating the underlying cause rather than the albumin level itself 2, 4:
- Address inflammation: Inflammatory cytokines directly downregulate hepatic albumin synthesis even with adequate protein intake 2
- Provide adequate nutrition: Protein intake of 1.2-1.3 g/kg body weight/day with 30-35 kcal/kg/day 2
- Correct fluid overload: Hemodilution from excess fluid decreases serum albumin concentration 2
- Minimize protein losses: Treat proteinuria or reduce dialysate losses 2
Common Pitfall
The most critical error is assuming hypoalbuminemia is solely due to nutritional deficiency when inflammation is often the primary driver 2. Serum albumin is a marker of disease severity and inflammation rather than nutritional status in acute illness 2, 8. Aggressive treatment of the underlying disease is far more important than albumin replacement 4.