Albumin Infusion in Nephrotic Syndrome in Adolescents

Clinical Indications

The American Academy of Pediatrics and nephrology experts recommend albumin infusion for adolescents with nephrotic syndrome who have clinical indicators of hypovolemia, such as prolonged capillary refill time, tachycardia, hypotension, oliguria, abdominal discomfort, or failure to thrive, not based on serum albumin levels alone 1, 2, 3
Clinical signs requiring albumin consideration include prolonged capillary refill time, tachycardia, hypotension, oliguria, acute kidney injury, abdominal discomfort, and failure to thrive 1, 2, 3, 7

The initial dose of albumin should be 1-4 g/kg/day, with frequency and dosage titrated based on clinical response to hypovolemia indicators, not serum albumin levels 4, 5, 6, 8, 9, 10, 7
For stable or improving patients, reduce albumin dose and frequency as clinical status improves, and consider spacing out or stopping albumin infusions entirely 4, 5, 6, 8, 9, 10, 7

Consider administering furosemide 0.5-2 mg/kg IV bolus at the end of each albumin infusion in the absence of marked hypovolemia or hyponatremia 4, 5, 6, 8, 9, 10, 7

Avoid central venous lines whenever possible due to high risk of thrombosis and the need to preserve vasculature for future hemodialysis access 4, 5, 6, 8, 9, 10, 7
Use diuretics with caution, only in cases of intravascular fluid overload, as they can induce or worsen hypovolemia and promote thrombosis 4, 5, 6, 8, 9, 10, 7
Furosemide infusions must be administered over 5-30 minutes to avoid ototoxicity 4, 5, 6, 8, 9, 10, 7, 11
High doses of furosemide (>6 mg/kg/day) should not be given for more than 1 week due to risk of permanent hearing loss 4, 5, 6, 8, 9, 10, 7, 11, 12

Do not use serum albumin levels as the sole indication for albumin infusion, as this leads to unnecessary treatment and increased complications 1, 2, 6, 8, 3, 9, 7
Do not administer albumin or diuretics in patients with marked hypovolemia, hypotension, severe hyponatremia, or anuria, as this worsens outcomes 4, 5, 6, 8, 9, 10, 7, 11
Avoid routine albumin infusions in asymptomatic patients, as retrospective studies show no difference in long-term outcomes between regular albumin protocols and as-needed administration 6, 8, 9, 7