• Human derived blood product manufactured from donated human plasma - see Principles of Transfusion guideline
• Licenced for restoration and maintenance of circulating blood volume where demonstrated volume deficiency and use of non-artificial colloid is appropriate (however NOTE trial data shows few applications of albumin that improve patient outcome) 
• National albumin shortage declared August 2024
• More expensive to manufacture and to provide to patients, when compared with crystalloids 
• Available as: 
  
  • 20% (200 g/L) HAS for infusion: 100 mL (20 g human albumin) or 50 mL (10 g human albumin)
  • 4.5% (45 g/L) or 5% (50 g/L) HAS for infusion depending on current product stocked/recommendations by national framework: 250 mL (approximately 12 g) or 500 mL (approximately 25 g) 
• 20% is hyperoncotic so 100 mL volume will expand to approximately 400 mL within 25 min of transfusion
  
  • administration can lead to rapid volume expansion and cardiac failure
• Store in transfusion laboratory/pharmacy at controlled temperature <25°C for <2 yr
• To prevent inappropriate storage/wastage, maximum 2 bottles HAS can be removed from temperature-controlled storage at a time
• Must not be kept on unmonitored ward areas
  
  • return unused HAS to transfusion laboratory immediately (<30 min of issue, to facilitate return to stock)

Therapeutic apheresis (plasma exchange)

• Replacement fluid for plasma exchange as per American Society for Apheresis (ASFA) guidelines2023  according to apheresis indication 
  
  • guidance also specifies volume of exchange and frequency 
• For neurological indications e.g. myasthenia gravis, Guillain-Barre syndrome, autoimmune encephalitis, neuromyelitis optica - consider intravenous immunoglobulin (National commissioning criteria 2024)

Decompensated cirrhosis

• Following large volume paracentesis (>5 L) to avoid post-paracentesis circulatory dysfunction (PPCD) i.e. hyponatraemia and renal impairment (high level evidence, strong recommendation)
  
  • HAS 20% 8 g albumin/L (e.g. 40 g HAS for 5 L)
  • infuse after paracentesis of >5 L is complete 
  • maximum issue HAS 500 mL (100 g) per patient for paracentesis
• In patients undergoing paracentesis of <5 L, risk of developing PPCD is low. Consider HAS in patients with acute on chronic liver disease or high risk of post-paracentesis (low quality evidence, weak recommendation)
  
  • HAS 20% 8 g albumin/L
• Note: HAS not required in drainage of malignant ascites (see ascites guidance)
• Note: No difference in rate PPCD seen with high HAS dose of 6-8 g/L (grams albumin per litre ascitic fluid drained) versus low-dose HAS dose of 2-4 g/L

Cirrhosis and spontaneous bacterial peritonitis (SBP)

• Adjunct to antibiotics in treatment of SBP to reduce mortality and risk of renal impairment 
• Dose 1.5 g/kg ideal body weight (IBW) at diagnosis (within 6 hr) then 1 g/kg on day 3 (low certainty of evidence of effect) - see Prescription section for dosing support
  
  • do not use for infections other than SBP

Hepato-renal syndrome (HRS)

• Decompensated advanced liver disease with acute kidney injury – graded according to renal function hepatorenal syndrome  acute kidney injury (HRS-AKI) severity (see HRS-AKI stage according to urine output criteria below)
• HRS-AKI stage >1A, give HAS with vasoconstrictors e.g. terlipressin 
  
  • HAS 1 g/kg IBW day 1 followed by 40 g day for duration of therapy (evidence poor, no RCT evidence)
• HRS-AKI stage according to renal function:
  
  • stage 1 = increase in serum creatinine of ≥27 units/mol/L within 48 hr or ≥50% from baseline
  • stage 2 = increase serum creatinine 2-2.9 x baseline
  • stage 3 = increase serum creatinine >3 baseline or >354 units/mol/L or requiring renal replacement 

HRS-AKI stage according to urine output criteria

• Stage 1 = <0.5 mL/kg/b.w./hr x 6-12 hr 
• Stage 2 = <0.5 mL/kg/b.w./hr x 12 hr
• Stage 3 = <0.5 mL/kg/b.w./hr x 24 hr/ anuria x 12 hr

Septic shock

• Consider in adults with sepsis or septic shock receiving large volumes of crystalloids/ unresponsive to first line management (randomised clinical trials in progress)

• Critically ill adult patients (including thermal injuries and acute respiratory distress syndrome (ARDS)) for first-line volume replacement OR to increase serum albumin levels 
• Critically ill adult patients in conjunction with diuretics for removal of extravascular fluid 
• Traumatic brain injury 
  
  • associated with worse outcome 
• Subarachnoid haemorrhage and stroke 
• Trauma and resuscitation 
• Hypoalbuminaemia following critical illness associated with trauma
  
  • no improvement in ventilator free days, ICU length of stay, hospital length of stay 
• Patients undergoing kidney replacement therapy 
  
  • no role in preventing or treating intradialytic hypotension 
  • no improvement in ultrafiltration 
• Nephrotic syndrome 
  
  • no improvement in hypoalbuminemia or oedema and may exacerbate hypertension
• Patients undergoing cardiovascular surgery for priming cardiovascular bypass circuit OR volume replacement 
  
  • no improvement in mortality, kidney failure, blood loss, ICU length of stay, hospital length of stay, blood component use, or cardiac index 
• Cirrhosis and extraperitoneal infections
  
  • no reduction in mortality or kidney failure, higher pulmonary oedema 
• Cirrhosis, ascites and hypovolaemic hyponatraemia 
  
  • insufficient evidence to support use
• Hospitalised patients with decompensated cirrhosis and hypoalbuminemia
  • no reduction in mortality, infection rate or kidney failure if repeated infusions to increase albumin levels to >30 g/L 
• Outpatients with cirrhosis and uncomplicated ascites despite diuretic therapy
  
  • no reduction in complications associated with cirrhosis 

• Determine volume/dose on an individual indication and patient basis
• Where weight-based dosing applies, use Ideal Body Weight (IBW) (or actual weight where lower) 
• Round doses to nearest 10 g (50 mL). Maximum 100 g if dose 1 g/kg 
  
  • note risk fluid overload with doses >87 g 
• Infusion rate will vary according to indication (no UK published data)
  
  • ~30 min for 100 mL in LVP 
  • 30-120 min for other indications (complete within 4 hr)
  • high risk of cardiac failure with rapid infusion
• Ensure valid consent obtained and documented as plasma derived blood product
  
  • to revise - see Consent for transfusion guideline
• Adverse consequences of HAS include:
  
  • fluid overload
  • hypotension
  • haemodilution
  • anaphylaxis
  • peripheral gangrene
  • risks associated with plasma derived blood products
• Record batch numbers in clinical notes to ensure traceability is maintained

• Infuse using a standard giving set
• Do not dilute with water (as may cause haemolysis)
• Adjust the infusion rate according to the individual circumstances (see Prescription above)
• Monitor closely for adverse events including allergy and cardiovascular compromise

Assessing response to transfusion

• Clinical assessment and careful monitoring of patient to assess for response to treatment and any adverse events
• Monitor and adjust fluid and electrolyte therapy as clinically appropriate