What is the recommended infusion rate of 25% albumin in patients undergoing hemodialysis for hypovolemia or hypoalbuminemia?

Albumin Infusion Rate During Hemodialysis

For hypoalbuminemic patients (albumin <3.0 g/dL) undergoing hemodialysis, administer 100 mL of 25% albumin intravenously at the initiation of dialysis, which can be given over approximately 15-30 minutes based on the patient's hemodynamic tolerance. 1

Evidence-Based Administration Protocol

Standard Dosing and Timing

• The highest quality evidence comes from a 2021 randomized crossover trial demonstrating that 100 mL of 25% albumin given at dialysis initiation significantly reduced intradialytic hypotension (7% vs 15% with saline, p=0.002) and improved ultrafiltration rates in hypoalbuminemic patients 1
• This dosing regimen (100 mL of 25% albumin = 25 grams) can be administered at the start of each dialysis session for patients with serum albumin <3.0 g/dL 1

Infusion Rate Considerations

• The FDA label for 25% albumin (Plasbumin-25) states that in hypoproteinemic patients with approximately normal blood volumes, the rate should not exceed 2 mL per minute to avoid circulatory embarrassment and pulmonary edema 2
• For the standard 100 mL dose, this translates to a maximum infusion time of 50 minutes, though faster rates (15-30 minutes) are commonly used in clinical practice when hemodynamically stable 2, 1
• In other clinical contexts (paracentesis), albumin infusion rates of 80-320 mL/hour have been used safely, suggesting flexibility based on patient tolerance 3

Clinical Benefits in the Hemodialysis Population

Hemodynamic Improvements

• Albumin administration before dialysis resulted in significantly higher lowest intradialytic systolic blood pressure (90 mmHg with albumin vs 83 mmHg with saline, p=0.035) 1
• Ultrafiltration rates improved significantly with albumin (8.27 ml/kg/h vs 8.25 ml/kg/h with saline, p=0.011), allowing better fluid removal 1
• These benefits are particularly pronounced when baseline serum albumin is ≤2.5 g/dL, as hypoalbuminemia acts as an effect moderator for albumin's volume expansion properties 4

Critical Safety Considerations

Monitoring Requirements

• Watch for signs of circulatory overload, particularly pulmonary edema, which occurred in 13% of patients receiving rapid high-dose albumin infusions in stroke trials 3
• The risk of fluid overload is lower with 25% albumin compared to crystalloids due to its oncotic properties and smaller infusion volume 5
• Monitor blood pressure continuously during infusion, especially in patients with compromised cardiac function 2

Membrane-Related Albumin Losses

• Be aware that certain high-flux dialyzer membranes (particularly steam-sterilized polyphenylene membranes) can cause massive albumin losses into dialysate during high-volume hemodiafiltration—up to 23.6 grams per session 6
• Standard high-flux hemodialysis with biocompatible membranes typically results in albumin losses of 4-6 grams per session 6
• Switching from bioincompatible to biocompatible membranes (e.g., cuprammonium to polysulfone) can improve serum albumin levels (3.22 to 3.35 g/dL, p<0.002) 7

Practical Implementation Algorithm

Patient Selection

• Target patients with serum albumin <3.0 g/dL who experience recurrent intradialytic hypotension 1
• Consider albumin supplementation when large ultrafiltration volumes are needed but limited by hypotensive episodes 1

Administration Protocol

1. Draw up 100 mL of 25% albumin solution
2. Administer intravenously at dialysis initiation
3. Infuse over 15-30 minutes if hemodynamically stable, or slower (up to 50 minutes) if concerned about fluid tolerance 2, 1
4. Monitor vital signs every 15 minutes during infusion 1
5. Proceed with standard hemodialysis prescription 1

Cost-Benefit Considerations

• Annual albumin costs for maintenance hemodialysis can reach $20,000 per patient, but this must be weighed against reduced hospitalizations from intradialytic complications 5
• The concentrated 25% formulation is more cost-effective per gram of albumin delivered compared to 5% solutions 5

Common Pitfalls to Avoid

• Do not use albumin to treat hypoalbuminemia alone without addressing the underlying cause or specific clinical indication like intradialytic hypotension 3
• Avoid excessively rapid infusion (>2 mL/min in volume-sensitive patients) as this increases pulmonary edema risk 2
• Do not assume all dialyzer membranes are equivalent—some high-flux membranes cause excessive albumin losses that may negate the benefits of supplementation 6
• Recognize that 58% of infused albumin undergoes increased degradation, so repeated dosing may be necessary for sustained benefit 8