From the Guidelines
Albumin should be administered after large volume paracentesis when more than 5 liters of ascitic fluid is removed, at a dose of 8 g albumin/L of ascites removed. This recommendation is based on the most recent and highest quality study, which provides strong evidence for the use of albumin in this setting 1. The guidelines on the management of ascites in cirrhosis, published in Gut in 2021, state that albumin should be infused after paracentesis of >5 L is completed at a dose of 8 g albumin/L of ascites removed, with a high quality of evidence and a strong recommendation 1.
Some key points to consider when administering albumin after large volume paracentesis include:
- The recommended dose is 8 g albumin/L of ascites removed, which can be given as a 20% or 25% solution 1
- Albumin should be infused immediately after the procedure or within 6 hours to prevent post-paracentesis circulatory dysfunction (PPCD) 1
- PPCD is a condition characterized by rapid plasma volume expansion, activation of vasoconstrictor systems, and potential kidney injury, which can be prevented by albumin replacement 1
- Smaller volume paracenteses (less than 5 liters) generally don't require albumin replacement as the risk of PPCD is significantly lower, although it can be considered in patients with ACLF or high risk of post-paracentesis acute kidney injury 1
Overall, the use of albumin after large volume paracentesis is a well-established practice that helps prevent PPCD and its associated complications, and should be administered according to the recommended dose and guidelines 1.
From the FDA Drug Label
Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume. The total dose should not exceed the level of albumin found in the normal individual, i.e., about 2 g per kg body weight in the absence of active bleeding.
The recommended cut off volume to give albumin after large volume paracentesis is not explicitly stated, but it is suggested that the total dose of albumin should not exceed 2 g per kg body weight.
- The patient's hemodynamic response should be monitored and the usual precautions against circulatory overload observed.
- Albumin infusion may be required to support the blood volume in patients with cirrhosis after removal of ascitic fluid. 2
From the Research
Albumin Infusion after Large Volume Paracentesis
- The use of albumin infusion after large volume paracentesis (LVP) has been studied to reduce paracentesis-induced circulatory dysfunction (PICD) 3, 4, 5, 6, 7.
- A study published in 2020 found that standardizing albumin doses 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 3.
- The optimal dose of albumin for LVP is unclear, but a study suggested that 6-8 g of albumin per liter of ascites drained may be effective in preventing PICD 5.
- A meta-analysis published in 2012 found that albumin infusion reduced the incidence of PICD, hyponatremia, and mortality compared to alternative treatments 4.
- Another study published in 2021 found that albumin use reduced the odds of PICD by 60% and lowered the incidence of hyponatremia, but did not reduce overall mortality, readmission rate, recurrence of ascites, or other complications 7.
Criteria for Initiating Albumin Infusion
- The 2021 American Association for the Study of Liver Disease (AASLD) Practice Guidance recommends albumin infusion when removing ≥5 L of ascites to prevent PICD 6.
- A study published in 2024 found that albumin infusion at the threshold of 5 L of ascites removal reduced serum creatinine levels and increased serum sodium levels compared to those who did not receive albumin infusion 6.
- However, the study also suggested that the efficacy of albumin infusion in patients who undergo elective TP and have 3-5 L of ascites removed needs to be further evaluated 6.