When should intravenous (IV) albumin be used?

From the Guidelines

Intravenous (IV) albumin should be used in specific clinical scenarios, including large-volume paracentesis in cirrhotic patients, spontaneous bacterial peritonitis, and hepatorenal syndrome, as it has been shown to improve outcomes in these conditions. The use of IV albumin is supported by recent guidelines, including the AGA clinical practice update on the use of vasoactive drugs and intravenous albumin in cirrhosis 1. According to this guideline, IV albumin should be administered at the time of large-volume paracentesis, and may be considered in patients with spontaneous bacterial peritonitis.

The dosing of IV albumin varies depending on the specific condition being treated. For example, in patients with large-volume paracentesis, 6-8 g of albumin per liter of ascites removed is recommended 1. In patients with spontaneous bacterial peritonitis, 1.5 g/kg on day 1, followed by 1 g/kg on day 3, is recommended 1.

It is essential to note that IV albumin should not be used routinely for hypoalbuminemia without specific indications, as it provides only temporary benefit in such cases and carries risks including fluid overload, pulmonary edema, and allergic reactions 1. The decision to administer albumin should be based on the patient's clinical condition rather than solely on serum albumin levels.

Some key points to consider when using IV albumin include:

• IV albumin is indicated for patients with hypovolemia from acute blood loss when blood products are unavailable, severe burns, hypoalbuminemia with edema unresponsive to diuretics, and hepatorenal syndrome.
• The standard concentrations available are 5% and 25%, with dosing based on the specific condition being treated.
• Albumin works by increasing oncotic pressure in the intravascular space, drawing fluid from interstitial spaces into the circulation.
• IV albumin should not be used in patients with cirrhosis and uncomplicated ascites, as it has not been shown to improve outcomes in this condition 1.

Overall, the use of IV albumin should be guided by the patient's clinical condition and the specific indication for its use, rather than solely on serum albumin levels.

From the FDA Drug Label

Emergency Treatment of Hypovolemic Shock Plasbumin-25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. Although Plasbumin-5 is to be preferred for the usual volume deficits, Plasbumin-25 with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed. Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume. Burn Therapy ... Beyond 24 hours Plasbumin-25 can be used to maintain plasma colloid osmotic pressure. Hypoproteinemia With or Without Edema ... Treatment with Plasbumin-25 may be of value in such cases. Adult Respiratory Distress Syndrome (ARDS) ... When clinical signs are those of hypoproteinemia with a fluid volume overload, Plasbumin-25 together with a diuretic may play a role in therapy Cardiopulmonary Bypass ... preoperative dilution of the blood using albumin and crystalloid has been shown to be safe and well-tolerated Acute Liver Failure ... administration of albumin may serve the double purpose of supporting the colloid osmotic pressure of the plasma as well as binding excess plasma bilirubin Neonatal Hemolytic Disease ... The administration of Plasbumin-25 may be indicated prior to exchange transfusion, in order to bind free bilirubin, thus lessening the risk of kernicterus. Sequestration of Protein Rich Fluids ... The magnitude of loss into the third space may require treatment of reduced volume or oncotic activity with an infusion of albumin Erythrocyte Resuspension ... Albumin may be required to avoid excessive hypoproteinemia, during certain types of exchange transfusion, or with the use of very large volumes of previously frozen or washed red cells. Acute Nephrosis ... a loop diuretic and 100 mL Plasbumin-25 repeated daily for 7 to 10 days may be helpful in controlling the edema Renal Dialysis ... Plasbumin-25 may be of value in the treatment of shock or hypotension in these patients

Key Indications for IV Albumin:

• Hypovolemic shock: to expand plasma volume
• Oncotic deficits: to maintain plasma colloid osmotic pressure
• Burn therapy: beyond 24 hours to maintain plasma colloid osmotic pressure
• Hypoproteinemia: with or without edema
• Adult Respiratory Distress Syndrome (ARDS): with fluid volume overload
• Cardiopulmonary bypass: preoperative dilution of blood
• Acute liver failure: to support colloid osmotic pressure and bind excess plasma bilirubin
• Neonatal hemolytic disease: prior to exchange transfusion to bind free bilirubin
• Sequestration of protein rich fluids: to treat reduced volume or oncotic activity
• Erythrocyte resuspension: to avoid excessive hypoproteinemia
• Acute nephrosis: to control edema
• Renal dialysis: to treat shock or hypotension 2

From the Research

Indications for IV Albumin Use

• Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin 3
• Albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use 3
• Treatment of severe clinical complications in patients with cirrhosis, such as hepatorenal syndrome, and fluid resuscitation in critically ill patients, when crystalloids and non-proteic colloids are not effective or contra-indicated, represents the major evidence-based clinical indications for albumin administration 4
• Use of albumin in paracentesis was associated with significantly reduced risk of paracentesis-induced circulatory dysfunction and there was a nonsignificant difference in death, encephalopathy, hyponatraemia, readmission, and renal impairment 5
• In cirrhotic patients with any infection, there was a significant reduction in mortality and renal impairment when albumin was used 5

Contraindications and Precautions

• Albumin should not be used in hypoalbuminemia or for nutritional purpose 3
• Albumin is not recommended for long-term treatment of ascites, nephrotic syndrome, pancreatitis, abdominal surgery, acute distress respiratory syndrome, cerebral ischemia, and enteric diseases due to lack of clinical evidence of efficacy 4
• Hypo-oncotic albumin is not recommended in traumatic brain injury 6

Special Considerations

• Albumin administration is most indicated in management of cirrhosis complications 3
• Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin 3
• The use of albumin in volume therapy can be regarded as safe, except in traumatic brain injury 6