From the Guidelines
Albumin replacement is recommended when more than 5 liters of ascites are removed, with a dose of 8 grams of albumin per liter of ascites removed. This is based on the most recent and highest quality study, which suggests that albumin infusion is crucial to prevent postparacentesis circulatory dysfunction (PPCD) in patients undergoing large volume paracentesis 1. The use of albumin in this context has been shown to mitigate the risk of PPCD, which can lead to renal impairment, dilutional hyponatremia, hepatic encephalopathy, and death.
The recommended dose of albumin replacement is 6-8 grams for every liter of ascites removed, as stated in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1. This dose has been shown to be effective in preventing PPCD and its associated complications.
It is worth noting that the use of albumin in patients with ascites is not solely determined by the volume of ascites removed, but also by the patient's underlying condition and risk factors for PPCD. For example, patients with acute-on-chronic liver failure (ACLF) or high risk of post-paracentesis acute kidney injury may benefit from albumin replacement even if less than 5 liters of ascites are removed 1.
In summary, the key points to consider when determining the need for albumin replacement in patients with ascites are:
- More than 5 liters of ascites are removed
- Patient has ACLF or high risk of post-paracentesis acute kidney injury
- Dose of 8 grams of albumin per liter of ascites removed
- Albumin replacement is crucial to prevent PPCD and its associated complications.
Overall, the decision to use albumin replacement should be based on a careful assessment of the patient's individual needs and risk factors, and should be guided by the most recent and highest quality evidence available 1.
From the Research
Albumin Replacement Levels
- The level of albumin that needs replacement is not explicitly stated in the provided studies, but it is mentioned that hypoalbuminemia is a condition where albumin levels are lower than normal 2, 3, 4, 5, 6.
- According to 5, severe hypoalbuminemia is defined as a baseline serum albumin level of less than 3.0 g/dL.
- The study 5 found that the presence of severe hypoalbuminemia at baseline was associated with a 2.5 times higher chance of responding to intradialytic parenteral nutrition (IDPN) therapy.
- Another study 2 mentions that fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin.
- However, the study 3 states that treatment of hypoalbuminemia is that of the underlying causes and associated conditions, such as a low plasma volume, not of hypoalbuminemia per se.
- The study 6 suggests that hypoalbuminemia is one of many parameters of malnutrition, and it is unlikely that correction of a single parameter for a short time would lead to major clinical benefits.
Indications for Albumin Administration
- The study 2 provides evidence-based instructions for the administration of albumin in clinical practice, including:
- Fluid replacement in plasmapheresis and liver diseases
- Resuscitation in shock states, especially distributive shocks such as septic shock
- Liver disease, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis
- The study 4 mentions that serum albumin levels are commonly ordered in intensive care unit (ICU) settings to guide albumin administration, estimate free phenytoin or calcium levels, for nutritional monitoring, and for severity-of-illness assessment.