What is the role of albumin infusion in protein-losing enteropathy?

From the Guidelines

Albumin infusion should not be considered a primary treatment for protein-losing enteropathy (PLE), but rather as a supportive therapy for acute management of severe hypoalbuminemia. For patients with PLE, a low-fat, high-protein, MCT diet may be successful in managing hypoalbuminemia, gastrointestinal symptoms, and growth, as suggested by the ESPEN guideline on hospital nutrition 1.

In terms of albumin infusion, it can be used to temporarily improve severe hypoalbuminemia (typically <2.0 g/dL) with associated symptoms like edema or ascites. The recommended dose is 25% albumin administered at 0.5-1 g/kg/day, infused slowly over 2-4 hours, and limited to short courses of 3-5 days. Concurrent diuretic therapy with furosemide (20-40 mg IV with each albumin infusion) is often recommended to prevent fluid overload.

Key considerations in the management of PLE include:

• Addressing the underlying cause of PLE, which may include inflammatory bowel disease, lymphatic obstruction, or cardiac conditions
• Nutritional support with a low-fat, high-protein diet and medium-chain triglyceride supplementation for long-term management
• Monitoring serum albumin levels, weight, and edema during therapy
• Recognizing that without treating the underlying condition, albumin levels will quickly return to pre-infusion values.

Other medical therapies, such as aldosterone antagonists, subcutaneous unfractionated heparin, PAH therapies, corticosteroids, and octreotide, may be considered in specific cases, as discussed in the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1. However, the primary focus should be on addressing the underlying cause of PLE and providing nutritional support.

From the FDA Drug Label

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 use of albumin infusion in protein-losing enteropathy is not justified as a source of protein nutrition, according to the FDA drug label 2.

From the Research

Use of Albumin Infusion in Protein Losing Enteropathy

• The use of albumin infusion in protein losing enteropathy (PLE) is a topic of interest in the management of this condition 3.
• PLE is a rare syndrome of gastrointestinal protein loss that may complicate a variety of diseases, including inflammatory bowel diseases (IBD) 4, 5, 3.
• The diagnosis of PLE is based on the determination of fecal alpha-1 antitrypsin clearance and stool analysis 4, 5, 3.
• Treatment of PLE targets the underlying disease, but also includes dietary modification, supportive care, and maintenance of nutritional status 4, 5, 3.
• In severe cases of hypoalbuminemia and fluid retention, albumin infusion may be necessary to manage the condition 3.
• The prognosis of PLE depends on the patient and the disease location, severity, and complication 3.

Albumin Infusion in Specific Cases

• In a case of Crohn's disease with significant hypoproteinemia, albumin infusion was used to manage the condition, but the patient eventually required surgical resection of the affected area 5.
• In patients with cirrhosis and hypoalbuminemia, protein-losing enteropathy may be an underestimated cause of hypoproteinemia, and albumin infusion may be necessary in some cases 6.
• The use of albumin infusion in PLE is generally reserved for severe cases, and the decision to use it should be made on a case-by-case basis 3.

Mechanism of Protein Loss

• The mechanism of protein loss in PLE is complex and involves the rupture of mucosal lymphatics, macroscopic breakdown of the mucosal barrier, and increased lymphatic pressure 7.
• The equation derived to describe the relationship between the reduction in serum albumin and PLE indicates that gastrointestinal albumin clearance must increase by at least 17 times normal to reduce the serum albumin by half 7.
• The use of alpha-1 antitrypsin clearance as a diagnostic test for PLE is a simple and quantitative method that is probably underused clinically 7.