Albumin Transfusions: Clinical Applications and Evidence

Introduction to Albumin

Albumin is administered intravenously as a human-derived blood product available in different concentrations (typically 5%, 20%, or 25%) 1, 2
Albumin is more expensive than crystalloids (approximately $130/25g in US dollars) 1

The American Thoracic Society recommends albumin for patients with cirrhosis undergoing large-volume paracentesis (conditional recommendation, moderate certainty of evidence) 3
The American Thoracic Society recommends albumin for patients with spontaneous bacterial peritonitis (conditional recommendation, moderate certainty of evidence) 3

The American Thoracic Society does not recommend albumin for critically ill adult patients (excluding thermal injuries and ARDS) for first-line volume replacement or to increase serum albumin levels 3, 1, 2
The American Thoracic Society does not recommend albumin for neonatal and pediatric critical care for routine use 3
The American Thoracic Society does not recommend albumin for cardiovascular surgery for routine use 3
The American Thoracic Society does not recommend albumin for kidney replacement therapy for routine use 3

Fluid overload is a potential adverse effect of albumin transfusion 1
Hypotension is a potential adverse effect of albumin transfusion 1
Hemodilution requiring RBC transfusion is a potential adverse effect of albumin transfusion 1
Anaphylaxis is a potential adverse effect of albumin transfusion 1
Peripheral gangrene from dilution of natural anticoagulants is a potential adverse effect of albumin transfusion 1

Multiple ongoing large randomized clinical trials are investigating albumin use in hypoalbuminemic patients with community-acquired pneumonia 3
Multiple ongoing large randomized clinical trials are investigating albumin use in septic shock 3
Multiple ongoing large randomized clinical trials are investigating albumin use in high-risk cardiac surgery 3
Multiple ongoing large randomized clinical trials are investigating albumin use in long-term administration for decompensated cirrhosis with ascites 3
Multiple ongoing large randomized clinical trials are investigating albumin use in acute kidney injury requiring kidney replacement therapy 3

The American Thoracic Society recommends that the treatment of hypoalbuminemia should focus on addressing the underlying cause rather than simply correcting the low albumin level, as albumin infusion is not recommended for routine treatment of hypoalbuminemia alone 4

The European Society of Gastrointestinal Endoscopy suggests providing adequate nutritional support, especially in malnourished patients 5

The American Association for the Study of Liver Diseases recommends albumin infusion for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis 4
For patients with hyponatremia and cirrhosis, the American Association for the Study of Liver Diseases suggests a trial of fluid restriction to 1,000 mL/day for moderate hyponatremia (120-125 mEq/L) 6
The International Society of Nephrology recommends basing albumin infusion frequency and dosage on clinical indicators of hypovolaemia rather than serum albumin levels in patients with congenital nephrotic syndrome 7
The Society of Critical Care Medicine suggests that intravenous albumin is not recommended for first-line volume replacement or to increase serum albumin levels in critically ill adult patients 4
The World Society of Emergency Surgery recommends supportive measures, including intravenous fluid resuscitation, albumin supplementation, and electrolyte replacement, for patients with severe C. difficile infection 8
The European Society of Surgical Research notes that preoperative hypoalbuminemia (<30 g/L) is associated with a higher risk of postoperative intra-abdominal sepsis 9

The American College of Chest Physicians suggests considering albumin infusion as second-line and adjunctive to crystalloids for fluid resuscitation in specific conditions, such as intradialytic hypotension 10
The European Society of Gastrointestinal Endoscopy recommends considering albumin infusion for major surgery 5