Intravenous albumin is a concentrated solution of human serum albumin, the most abundant protein in blood plasma. Its primary physiological roles include maintaining oncotic pressure, transporting hormones and drugs, and buffering the extracellular environment. When disease states disrupt these functions or when rapid fluid shifts threaten organ perfusion, clinicians may supplement the patient’s own reserves with blood products. Although it has been used in medicine for decades, indications for intravenous albumin remain specific and grounded in evidence, as albumin is costly and not without risks.
One of the most well-established indications for intravenous albumin is in the management of cirrhosis, particularly when complications arise from portal hypertension and systemic inflammation. Patients undergoing large-volume paracentesis for tense ascites—abnormal buildup of fluid in the abdomen most commonly caused by cirrhosis— may experience significant reductions in intravascular volume as fluid is removed from the peritoneal cavity. Albumin administration after removal of more than five liters of ascitic fluid reduces the risk of paracentesis-induced circulatory dysfunction, a condition that can worsen renal function and increase mortality. In another cirrhosis-related scenario, albumin is essential in treating spontaneous bacterial peritonitis. When combined with antibiotics, albumin helps maintain renal perfusion and reduces the incidence of hepatorenal syndrome by counteracting the profound vasodilation and fluid redistribution characteristic of advanced liver disease.
Albumin also plays a role in the management of hepatorenal syndrome itself, particularly in conjunction with vasoconstrictor therapies. By expanding plasma volume, albumin supports the kidneys during a state of extreme circulatory dysfunction. This therapeutic combination can improve survival and delay the need for renal replacement therapy, although it does not cure the underlying liver pathology.
In critical care, albumin may be indicated for specific forms of shock, especially when crystalloids alone fail to restore adequate intravascular volume. Sepsis is one such condition, where capillary leakage and widespread inflammation can cause significant fluid shifts out of the bloodstream. Some studies suggest that albumin can help maintain oncotic pressure and improve hemodynamic stability in severe sepsis or septic shock. While crystalloid fluids remain the first-line treatment, albumin may be considered for patients requiring large volumes of resuscitation fluids or for those with hypoalbuminemia contributing to hemodynamic instability.
Burn injuries present another scenario in which albumin may be used, though typically after the initial resuscitation phase. Extensive burns increase vascular permeability, allowing fluid and proteins to leak into damaged tissues. Once capillary integrity begins to return, albumin can help restore circulating volume and reduce edema. Because timing is crucial, albumin is generally reserved for later phases of burn care rather than the immediate response to injury.
Hypoalbuminemia itself is not an automatic indication for albumin infusion. Low serum albumin levels often reflect chronic illness, inflammation, or poor nutrition rather than a lack of circulating protein that can be corrected with supplementation. However, when hypoalbuminemia occurs alongside acute illness, severe edema, or difficulty maintaining intravascular volume, albumin may be used to enhance the effectiveness of diuretic therapy. Patients with nephrotic syndrome, for example, may receive albumin along with loop diuretics when edema is extreme and unresponsive to standard treatment. Even in this context, albumin use is cautious and targeted.
Across all these indications, the decision to use intravenous albumin involves careful clinical judgement. While albumin can be lifesaving in select conditions, its benefits must be weighed against cost, limited resources, and potential risks such as fluid overload or allergic reactions. For these reasons, albumin therapy is best reserved for situations where its physiologic properties clearly offer an advantage offer simpler fluid therapies, and where evidence supports a meaningful impact on patient outcomes.
