Albumin Transfusion in Palliative Care: Clinical Guidelines

Background: Why Hypoalbuminemia Occurs in Palliative Patients

• Chronic inflammation (IL-6, TNF-alpha suppress hepatic synthesis)
• Cancer cachexia and malnutrition
• Third-spacing from liver/renal failure or malignancy
• Reduced oral intake

The Key Principle

Albumin should NOT be given merely to "correct" a low serum albumin level in palliative or advanced-illness patients. Hypoalbuminemia in this context is a marker of disease severity, not a treatable deficiency.

Evidence-Based Indications (Where Albumin MAY Be Given)

Where Albumin is NOT Recommended

Palliative Care-Specific Considerations

• Large-volume paracentesis with albumin replacement (6-8 g/L removed) is the standard of care and is appropriate even in palliative patients for symptom relief.
• Albumin given for ascites without paracentesis to "maintain oncotic pressure" is not supported.

Practical Summary

Key Reference

What You May Be Looking For

1. Could you mean the National Blood Transfusion Council (NBTC) / CDSCO India guidelines?

2. Could you mean NHA's clinical package definitions under Ayushman Bharat?

3. Could you mean a hospital/state authority called "NHA"?

Most Likely Match: Standard Indian Clinical Practice (NBTC/WHO Framework)

My Recommendation

• National Health Authority of India (Ayushman Bharat regulator)?
• A specific hospital or state authority?
• NHS (UK National Health Service) guidelines? (A common confusion in Indian medical education)

NHS UK Guidelines: Human Albumin Solution (HAS)

Available Formulations

APPROPRIATE INDICATIONS (Evidence-Based)

1. Large Volume Paracentesis (LVP) - Cirrhotic Ascites

• HAS is mandatory following drainage of >5 litres of ascitic fluid in cirrhosis to prevent post-paracentesis circulatory dysfunction (PPCD)
• Paracentesis without albumin causes a fall in pulmonary capillary wedge pressure (maximal at 6 hours) leading to circulatory and renal dysfunction

• Normal renal function: HAS 20% - 1 bottle (100 mL = 20 g) per every 3 litres drained
• Impaired renal function: HAS 20% - 1 bottle per every 2 litres drained
• Authorised by: Junior medical staff on advice of Gastroenterologist/ITU Consultant

2. Spontaneous Bacterial Peritonitis (SBP)

• Authorised by: Consultant Gastroenterologist or ITU Consultant

3. Hepatorenal Syndrome (HRS)

• HAS 20%: 1 g/kg/day (maximum 100 g/day) for 2+ days
• Continue daily (1-2 bottles/day) for up to 16 days, or until renal function improves
• Either 4.5% or 20% may be used depending on fluid status
• Authorised by: Consultant Gastroenterologist or ITU Consultant

4. Nephrotic Syndrome

• Short-term use in combination with diuretics for acute severe peripheral/pulmonary oedema
• Long-term albumin supplementation in nephrotic syndrome is NOT appropriate

5. Severe Burns (after first 24 hours)

• Burns resuscitation after the first 24 hours
• NOT before 24 hours - use before this time causes paradoxical pulmonary oedema
• Replaces subacute plasma volume loss

6. Therapeutic/Plasma Apheresis

• HAS 5%: 1-1.5 plasma volumes daily
• For large-volume exchanges (>20 mL/kg/session)
• Authorised by: Consultant Haematologist

7. Acute Liver Injury

• To support plasma oncotic pressure
• Binds excessive bilirubin, activated plasmin, and toxins
• Used in exchange transfusion in neonates (unconjugated bilirubinaemia)

8. ARDS (selective use)

• Only when diuretic use has caused a fall in effective plasma volume
• Not for routine volume resuscitation in ARDS

9. Renal Dialysis

• Only if the patient becomes hypotensive during dialysis
• Not routine

10. Critical Care (ICU/HDU)

• Low serum albumin in a haemodynamically unstable patient
• HAS 20% may occasionally be indicated
• Must be requested by Consultant Anaesthetist/Intensivist in ITU/HDU only

INAPPROPRIATE INDICATIONS (NHS Explicitly Lists These as NOT Appropriate)

Contraindications

1. Hypersensitivity to albumin or any excipients (absolute)
2. Conditions where hypervolaemia is dangerous:
   • Cardiac failure
   • Severe hypertension
   • Oesophageal varices
   • Pulmonary oedema
   • Haemorrhagic diathesis
   • Severe anaemia
   • Renal failure with no dialysis access

Administration (NHS Protocol)

Monitoring During Infusion

• Blood pressure and heart rate
• Central venous pressure (CVP) or pulmonary artery wedge pressure
• Urine output
• Electrolytes, haemoglobin, haematocrit
• Continuous cardiorespiratory observations

NHS Position on Palliative Care Specifically

"Low serum albumin in the absence of ascites, SBP, or hepatorenal syndrome - NOT usually indicated. Refer request to duty Pharmacist."

Quick Reference Summary Card

GIVE ALBUMIN (NHS approved):
✅ LVP >5L in cirrhosis → 20% HAS, 1 bottle per 3L drained
✅ SBP → 1.5 g/kg Day 1, 1 g/kg Day 3
✅ Hepatorenal syndrome + terlipressin → 1 g/kg/day (max 100 g)
✅ Nephrotic syndrome (acute, with diuretics)
✅ Burns after 24 hours
✅ Plasma exchange (large volume)
✅ Acute liver injury (oncotic support)

DO NOT GIVE ALBUMIN (NHS):
❌ Low albumin alone (any cause)
❌ Malnutrition / cachexia / TPN
❌ Palliative hypoalbuminaemia
❌ Major surgery / trauma volume replacement
❌ Burns in first 24 hours
❌ Ascites controlled by diuretics