3% vs. 5% Albumin in Plasma Exchange for Kidney Rejection: A Safe and Cost-Effective Option for Resource-Limited Settings?

Background: Antibody-mediated rejection (AMR) remains a major cause of graft loss in kidney transplant recipients. Therapeutic plasma exchange (TPE) is a cornerstone in AMR management, requiring the use of replacement fluids—typically 5% albumin, a costly formulation in many healthcare systems. Due to resource limitations, our center adopted the use of 3% albumin as a lower-cost alternative, despite limited evidence regarding its hemodynamic safety. Methods: We conducted a retrospective, cross-sectional, analytical study including 54 TPE sessions in 20 patients with biopsy-confirmed AMR at Hospital Juárez de México. Patients were grouped according to the albumin concentration used (3% vs. 5%). We analyzed hemodynamic parameters (mean arterial pressure [MAP], heart rate), incidence of hypotension (MAP < 65 mmHg), laboratory values, and direct treatment costs. Results: MAP remained stable across all time points evaluated (0, 30, 60, 90, and 120 minutes) in both groups, with no statistically significant differences. Hypotension was infrequent (10.7% in the 3% group vs. 3.6% in the 5% group; p = 0.61), and only one patient in the 3% group exhibited clinical symptoms. Heart rate remained within normal range and showed no relevant variation. Laboratory parameters, including serum albumin, calcium, and hemoglobin, remained within physiological limits, with no significant intergroup differences. Economic analysis revealed a significantly lower median cost in the 3% albumin group (approximately $880 USD) compared to the 5% albumin group (approximately $1,410 USD; p < 0.01), without compromising hemodynamic safety or clinical efficacy Conclusion: These findings support the use of 3% albumin as a safe and cost-effective replacement fluid during TPE for AMR. This approach may contribute to more sustainable resource utilization, particularly in low- and middle-income settings. Prospective, randomized controlled trials are warranted to further validate these results and guide future practice.