Albumin Stewardship — High-Yield Clinical Summary

1. Mechanism of Action

• Albumin is the primary plasma protein responsible for oncotic pressure
• Exogenous albumin acts as a colloid plasma volume expander
• ↑ intravascular oncotic pressure → fluid shifts from interstitial → intravascular space
• Available concentrations:
  • 5% albumin: iso-oncotic to plasma
  • 25% albumin: hyperoncotic (≈5× plasma expansion effect)
• Sodium content: ~145 mEq/L (important for sodium stewardship)

2. Crystalloid vs Colloid (Key Concept)

Clinical pearl:

• 250 mL 5% albumin → ~250 mL plasma expansion
• 50 mL 25% albumin → ~250 mL plasma expansion

3. Albumin Dosing Basics

• 1 unit = 12.5 g albumin (regardless of concentration)
• Doses may be ordered in grams or units
• Weight-based doses should be rounded up to nearest unit

4. Approved Indications (Stewardship-Supported)

✅ Approved / Supported

• Large-volume paracentesis
• Hepatorenal syndrome (HRS) – diagnosis & treatment
• Spontaneous bacterial peritonitis (SBP)
• Intradialytic hypotension
• Plasmapheresis
• Severe nephrotic syndrome
• Select distributive/hypovolemic shock cases

🚫 Not Approved / Contraindicated

• Traumatic brain injury (↑ mortality risk)
• ARDS
• Major trauma
• Hemorrhagic shock

Paracentesis — Core Stewardship Indication

When Albumin IS Indicated

• Large-volume paracentesis (LVP): >4 L removed
• <4 L removed, but ANY of the following:
  • SCr > 1.5 mg/dL
  • Serum Na < 130 mEq/L
  • SBP < 90 mmHg or on vasopressors
  • Hemodynamic instability

When Albumin Is NOT Needed

• Diagnostic paracentesis
• Therapeutic paracentesis <4 L without risk factors

Paracentesis Dosing

• 25% albumin: 6–8 g per liter removed
• Maximum dose: 50 g (4 units) if >5 L removed

Example:

• 6 L removed → 36–48 g albumin → round to 4 units (50 g)

Verification Checklist (Pharmacist / Resident)

1. Ensure “Other” indication is not used
2. Confirm volume removed (procedure note or nursing)
3. If <4 L removed, check:
   • Na <130
   • SBP <90 / pressors
   • SCr >1.5
4. Dose within 6–8 g/L
5. Correct concentration (25%, not 5%)

Hepatorenal Syndrome (HRS)

Key Concepts

• Functional renal failure in advanced cirrhosis
• Due to:
  • Portal HTN → splanchnic vasodilation
  • ↓ effective arterial volume
  • RAAS activation → renal vasoconstriction
• Diagnosis of exclusion

Albumin’s Role

• Diagnostic trial: volume expansion to rule out pre-renal AKI
• Therapeutic: used with vasoconstrictors (e.g., terlipressin, norepinephrine)

Stewardship Pitfalls to Avoid

❌ Using albumin as a general resuscitation fluid
❌ Albumin for ARDS or TBI
❌ Automatic albumin after small paracenteses
❌ Ignoring sodium load
❌ Overdosing beyond evidence-based caps

Take-Home Stewardship Principles

• Albumin ≠ benign crystalloid
• Use only when evidence-based
• Match indication → dose → concentration
• Always verify volume removed & renal risk
• Stewardship = patient safety + cost containment

Albumin Stewardship — Approved Indications (Advanced)

1. Hepatorenal Syndrome (HRS)

Role of Albumin in HRS

Albumin serves two distinct purposes in HRS:

1. Diagnostic volume challenge (to exclude pre-renal AKI)
2. Therapeutic adjunct (with vasoconstrictors)

HRS — Diagnostic Albumin Challenge

Purpose:

• Differentiate HRS from pre-renal azotemia

Criteria:

• No response to diuretic discontinuation
• No response to albumin volume expansion

Dosing (Diagnosis)

• 25% albumin
• Day 1: 1 g/kg (max 100 g)
• Day 2: 1 g/kg (max 100 g)

⚠️ Hard stop: Do not exceed 100 g/day

HRS — Treatment Dosing

If patient fails diagnostic challenge:

• 25% albumin
• 25–50 g/day
• ≥ 3 days, often longer
• Must be paired with vasoconstrictors

Common co-therapies (signal HRS intent):

• Midodrine + octreotide
• Norepinephrine
• Terlipressin

Verification Checklist — HRS

2. Intradialytic Hypotension (IDH)

Key Stewardship Principle

• Benefit only seen in hypoalbuminemia
• No evidence of benefit if albumin > 3.5 g/dL

IDH — Prevention Dosing

• 25% albumin
• 2–4 units (25–50 g)
• Administered prior to HD

Verification Checklist — IDH

✔ Serum albumin checked
✔ Albumin < 3.5 g/dL
✔ “Other” not selected
✔ Consider alternative strategies if albumin normal

📌 Stewardship pearl:
Albumin for IDH ≠ routine pre-HD med.

3. Spontaneous Bacterial Peritonitis (SBP)

Why Albumin Matters

• ↓ AKI
• ↓ Mortality
• One of the strongest evidence-based uses of albumin

Diagnostic Criteria

• Ascitic fluid PMN > 250 cells/mm³

PMN calculation:

Total WBC × % neutrophils = PMN count

SBP — Albumin Dosing

• 25% albumin
• Day 1: 1.5 g/kg (within 6 hours of diagnosis)
• Day 3: 1 g/kg
• Max: 100 g per dose

Verification Checklist — SBP

✔ Ascitic PMN confirmed
✔ Correct day of therapy (Day 1 vs Day 3)
✔ Weight-based dose calculated correctly
✔ Dose ≤ 100 g
✔ Appropriate antibiotics ordered (e.g., ceftriaxone, pip-tazo)

4. Plasmapheresis (PLEX)

Key Stewardship Points

• Albumin is a replacement fluid, not treatment
• 5% albumin only (not 25%)

PLEX Dosing

• 5% albumin
• Dose per NY Blood Bank MD / apheresis protocol

Verification Checklist — PLEX

✔ 5% albumin ordered
✔ “Other” not selected
✔ Calcium gluconate or chloride ordered

• Prevents citrate-induced hypocalcemia

5. Nephrotic Syndrome

Rationale

• Hypoalbuminemia → ↓ diuretic delivery to tubule
• Albumin + loop diuretic may overcome resistance

Nephrotic Syndrome Dosing

• 25% albumin
• 1–2 units (12.5–25 g)
• Must be paired with loop diuretic
  • Given concurrently or within 30–60 min

Verification Checklist — Nephrotic Syndrome

✔ 25% albumin selected
✔ Loop diuretic scheduled appropriately
✔ No severe electrolyte contraindications
✔ “Other” not selected

6. Hypovolemic or Distributive Shock

What Albumin Is NOT For

🚫 Hemorrhagic shock
🚫 Traumatic brain injury✔ “Other” not selected
✔ Diuretics held (especially during diagnostic phase)
✔ Albumin dose ≤ 100 g/day (diagnostic phase)
✔ Vasoconstrictor present if treating HRS
✔ Recent albumin exposure reviewed

Evidence Summary

• SAFE / ALBIOS: no mortality difference vs crystalloids
• Possible benefit in:
  • Cirrhosis + septic shock
• Surviving Sepsis 2021:
  • Weak recommendation
  • Consider after large-volume crystalloids
  • “Large-volume” not defined → requires judgment

Verification Checklist — Shock

✔ Type of shock confirmed
✔ Crystalloids already attempted
✔ No contraindications (TBI, hemorrhage)
✔ Case reviewed individually

Stewardship Bottom Line (Mental Model)

Albumin should answer one of three questions:

1. Does it prevent renal injury? (SBP, LVP)
2. Does it clarify diagnosis? (HRS challenge)
3. Does it restore oncotic effectiveness where crystalloids fail? (select cirrhosis cases)

If not → pause, verify, and question the order.