From the Guidelines
Albumin is indicated in patients with liver disease primarily for the management of ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS). The most recent and highest quality study, published in 2024 1, recommends albumin administration in select indications, including large-volume paracentesis, paracentesis-induced circulatory dysfunction, SBP, and HRS.
Key Indications for Albumin Use
- Large volume paracentesis: intravenous albumin at 6-8 g per liter of fluid removed to prevent post-paracentesis circulatory dysfunction
- Spontaneous bacterial peritonitis (SBP): albumin at 1.5 g/kg on day 1 and 1 g/kg on day 3 to reduce the risk of renal impairment and mortality
- Hepatorenal syndrome (HRS): albumin should be given at 1 g/kg on day 1 (maximum 100 g) followed by 20-40 g daily, in combination with vasoconstrictors like terlipressin or norepinephrine
Rationale for Albumin Use
Albumin works by expanding plasma volume, improving cardiac function, and binding toxins and inflammatory mediators. It also has antioxidant properties and helps maintain oncotic pressure, reducing fluid accumulation in tissues. However, albumin is not routinely recommended for treating uncomplicated ascites, hypoalbuminemia without specific complications, or for nutritional support in patients with liver disease.
Important Considerations
The use of albumin in patients with liver disease should be guided by the most recent and highest quality evidence, and should take into account the individual patient's clinical context and risk factors for complications. As noted in a 2021 study 1, the dose of albumin in patients with SBP should be carefully considered, with a recommended dose of 1.5 g/kg on day 1 and 1 g/kg on day 3, and with careful assessment of the patient's volume status, cardiovascular status, and degree of kidney impairment before transfusion.
From the FDA Drug Label
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. Acute Liver Failure(2) In the uncommon situation of rapid loss of liver function with or without coma, administration of albumin may serve the double purpose of supporting the colloid osmotic pressure of the plasma as well as binding excess plasma bilirubin Situations in Which Albumin Administration is Not Warranted(2) ...It is of occasional use in the rapid “priming” diuresis of nephrosis Similarly, in hypoproteinemic states associated with chronic cirrhosis, malabsorption, protein losing enteropathies, pancreatic insufficiency, and undernutrition, the infusion of albumin as a source of protein nutrition is not justified.
The indication for albumin in patients with liver disease includes:
- Supporting blood volume after removal of ascitic fluid in patients with cirrhosis to prevent hypovolemic shock 2
- Acute liver failure, to support colloid osmotic pressure and bind excess plasma bilirubin 2 However, albumin is not warranted in cases of chronic cirrhosis with hypoproteinemia, as it is not a justified source of protein nutrition 2
From the Research
Indications for Albumin in Liver Disease
- Albumin is indicated for use in patients with liver disease, particularly in the management of cirrhosis complications 3, 4, 5, 6, 7
- The main evidence-based indications for albumin administration in liver disease include:
- Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis 3, 4, 6
- Prevention of paracentesis-induced circulatory dysfunction and renal dysfunction induced by spontaneous bacterial peritonitis 5, 7
- Diagnosis and treatment of acute kidney injury and hepatorenal syndrome 7
- Long-term albumin administration in patients with decompensated cirrhosis has been shown to reduce mortality and incidence of complications, ease the management of ascites, and is cost-effective 5, 7
Specific Conditions
- Hepatorenal syndrome: albumin is used in combination with vasoconstrictors for management 4, 6
- Spontaneous bacterial peritonitis: albumin infusion reduces mortality 3, 4, 6
- Large-volume paracentesis: albumin infusion improves outcome 3, 4, 6
- Decompensated liver cirrhosis: long-term albumin administration reduces mortality and incidence of complications 5, 7