What is the intravenous (IV) albumin dose for large volume paracentesis?

From the Guidelines

For large volume paracentesis (LVP), the recommended albumin dose is 6-8 grams of albumin per liter of ascitic fluid removed when the total volume exceeds 5 liters. This is based on the most recent and highest quality study by the American Association for the Study of Liver Diseases 1. The albumin should be infused intravenously during or immediately after the paracentesis procedure.

Key Points

• For paracentesis removing less than 5 liters of fluid, albumin replacement is generally not necessary.
• The purpose of albumin administration is to prevent post-paracentesis circulatory dysfunction (PPCD), which can lead to rapid reaccumulation of ascites, hepatorenal syndrome, and increased mortality.
• Albumin works by expanding plasma volume and binding to vasodilatory substances, helping maintain effective arterial blood volume after the removal of large volumes of ascitic fluid.
• Patients should be monitored for signs of volume overload during administration, particularly those with cardiac or renal dysfunction.

Administration Details

• The recommended dose of albumin replacement is 6-8 g 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 can be administered as 25% albumin solution (25 g/100 mL), giving 25-50 mL (6.25-12.5 g) of 25% albumin per liter of ascitic fluid removed.

Supporting Evidence

• The use of albumin is supported by multiple studies, including those published in Hepatology 1, Gut 1, Journal of Hepatology 1, and Clinical and Molecular Hepatology 1.
• While some studies suggest that alternative plasma expanders may be effective, the most recent and highest quality evidence recommends the use of albumin 1.

From the Research

Albumin Dosing for Large Volume Paracentesis

• The optimal dose of albumin for large volume paracentesis (LVP) is unclear, but studies suggest that it can be standardized based on the amount of ascitic fluid removed 2.
• A study found that albumin doses can be standardized to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L) 2.
• Another study used 6-8 g of albumin per liter of ascites drained, with a maximum of 8 L removed 3.
• A meta-analysis found that albumin infusion reduces the incidence of postparacentesis circulatory dysfunction, hyponatremia, and mortality compared to alternative treatments 4.
• Reducing albumin dosing during LVP is not associated with adverse clinical outcomes, and guidelines can be safely followed to reduce albumin administration and associated costs 5.

Key Findings

• The incidence of paracentesis-induced circulatory dysfunction (PICD) is higher with dextran than with albumin (87.5% vs 38.5%) 6.
• The use of an order set to guide albumin dosing based on the amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given with no difference in adverse effects 2.
• Albumin infusion may prevent the morbidity of PICD in cirrhosis and refractory ascites, but the occurrence of PICD may not have a significant short- and long-term impact on renal function or cirrhosis-related complications 3.

Albumin Dosing Recommendations

• Salt-free human albumin should be the plasma expander of choice, especially if at least 8 liters are evacuated 6.
• Albumin doses can be standardized based on the amount of ascitic fluid removed, with 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L) being suggested doses 2.
• Reducing albumin dosing during LVP is not associated with adverse clinical outcomes, and guidelines can be safely followed to reduce albumin administration and associated costs 5.