Should You Administer 20% Albumin Now?
No, do not administer 20% albumin at this time. The elevated WBC count of 25,000/µL suggests a possible infection, but albumin is only indicated for specific complications in cirrhotic patients—not for acute hepatocellular injury with hypoalbuminemia alone or for infection without spontaneous bacterial peritonitis (SBP). 1
Critical First Steps: Rule Out Infection
Your immediate priority is to identify whether this patient has spontaneous bacterial peritonitis, as this is the only non-SBP infection where albumin may be beneficial:
- Perform diagnostic paracentesis immediately if ascites is present, with cell count and culture of ascitic fluid 1
- SBP is diagnosed when polymorphonuclear cells >250/mm³ in ascitic fluid 1
- Search systematically for other infection sources: blood cultures, urinalysis, chest imaging 1
- The elevated WBC alone does not justify albumin administration without confirming SBP 1
When Albumin IS Indicated in This Clinical Context
If SBP is Confirmed:
Administer albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3 in addition to antibiotics 1, 2
- This reduces acute kidney injury (10% vs 33%) and mortality (10% vs 29%) compared to antibiotics alone 1
- Patients with bilirubin >4 mg/dL or creatinine >1.0 mg/dL benefit most from albumin 1
- Your patient has normal bilirubin, which makes them lower risk for albumin benefit unless renal dysfunction develops 1
If Non-SBP Infection is Found:
Do NOT administer albumin 1
- Three RCTs and meta-analysis show albumin does not reduce AKI or mortality in non-SBP infections 1
- Albumin was associated with more pulmonary edema in these patients 1
- Exception: If sepsis-induced hypotension develops, consider 5% albumin over normal saline 2
Why Albumin is NOT Indicated Right Now
Low Total Protein Alone is Not an Indication:
- Albumin should not be used to correct hypoalbuminemia in cirrhosis 1, 2
- The 2024 International Collaboration for Transfusion Medicine Guidelines explicitly recommend against routine albumin for hypoalbuminemia correction 1
- Infused albumin provides no benefit for chronic hypoproteinemic states and is not justified as protein nutrition 3
Acute Hepatocellular Injury Without Specific Complications:
- Your patient has no encephalopathy, normal bilirubin, and no confirmed infection 1
- Albumin is not indicated for general volume replacement in critically ill cirrhotic patients 1, 2
- Balanced crystalloids (lactated Ringer's) are preferred for initial resuscitation 2, 4
Critical Safety Concerns if You Administer Albumin Inappropriately
Risk of Pulmonary Edema:
- The ATTIRE trial showed maintaining elevated albumin levels in decompensated cirrhosis increased pulmonary edema rates 2, 4, 5
- 20% albumin is hyperoncotic and can cause volume overload by drawing 3-4 times its volume from interstitial spaces 3
- Immediately discontinue albumin if pulmonary edema develops 5
Monitoring Requirements if Albumin is Given:
- Perform transthoracic echocardiography to assess cardiac function and volume status before administration 4, 5
- Monitor continuously for respiratory distress and declining oxygen saturation 5
- Watch for signs of fluid overload: increased work of breathing, crackles, declining SpO₂ 5
Your Action Plan
- Perform diagnostic paracentesis now if ascites present to rule out SBP 1
- Obtain blood cultures and search for infection sources systematically 1
- Use balanced crystalloids (lactated Ringer's) for any volume resuscitation needs 2, 4
- Reserve albumin only if SBP is confirmed with appropriate dosing (1.5 g/kg day 1.0 g/kg day 3) 1
- Do not give albumin for hypoalbuminemia correction or non-SBP infections 1
Common Pitfall to Avoid
The most common error is administering albumin simply because the patient has cirrhosis with low albumin and an elevated WBC. This is not an indication and may cause harm through volume overload. 1, 2 Albumin in cirrhosis requires specific complications: large-volume paracentesis (>5L), confirmed SBP, hepatorenal syndrome, or sepsis-induced hypotension. 1, 2