How to manage ascites with albumin administration?

From the Guidelines

Drain large-volume ascites (>5 L) and administer intravenous albumin at 6-8 g per liter of ascitic fluid removed. This approach is based on the most recent and highest quality study, which recommends albumin infusion at the time of large-volume paracentesis (LVP) to mitigate the risk of post-paracentesis circulatory dysfunction (PPCD) 1.

Procedure

• Perform paracentesis to drain ascitic fluid.
• For every liter of fluid removed, give 6-8 g of albumin IV.
• Administer albumin as a 20% or 25% solution.
• Infuse albumin during or immediately after the paracentesis.

Additional Considerations

• Monitor vital signs and electrolytes during and after the procedure.
• Limit fluid removal to 5-6 L per session to reduce the risk of complications.
• Consider diuretic therapy after drainage to prevent rapid reaccumulation.

The rationale behind this approach is that albumin administration helps maintain intravascular volume and reduces the risk of PPCD, which can lead to complications such as hypotension, renal impairment, and hyponatremia 1. Albumin replacement supports oncotic pressure and helps mobilize third-space fluid back into the circulation. This is consistent with the recommendations from other studies, which also suggest the use of albumin in patients undergoing LVP of greater than 5 L of ascites 1. However, the most recent study from 2021 provides the strongest evidence for this approach 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.

• Management of ascites with albumin administration involves using albumin infusion to support blood volume after removal of ascitic fluid, especially in patients with cirrhosis.
• The dosage is not explicitly stated for ascites management, but the general guideline for total dose is not to exceed 2 g per kg body weight in the absence of active bleeding 2.

From the Research

Management of Ascites with Albumin Administration

• The administration of albumin is recommended to prevent circulatory dysfunction after large-volume paracentesis (LVP) of more than 5 L of ascitic fluid 3, 4, 5
• The dosage of albumin to be administered is typically 6-8 g per liter of fluid removed 3, although some studies suggest standardizing the dose to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L) 5
• Albumin administration has been shown to reduce paracentesis-induced circulatory dysfunction (PICD) 5
• However, the combination of octreotide and midodrine is not superior to albumin in preventing recurrence of ascites after LVP 6

Alternative Treatments for Refractory Ascites

• Transjugular intrahepatic portosystemic shunt (TIPS) placement is an effective therapy for patients with refractory ascites, but it is not suitable for all patients due to contraindications 3, 7, 4
• The placement of a tunneled peritoneal drainage catheter is a viable and effective treatment alternative for patients with refractory ascites, reducing diuretic intake and the need for paracentesis 7
• Liver transplantation is the only effective therapy for patients with refractory ascites associated with cirrhosis, but it is not available for many patients 3

Patient Outcomes and Safety

• The use of albumin after LVP does not appear to have a significant impact on patient outcomes such as hyponatremia, renal impairment, and hypotension 5
• However, the combination of octreotide and midodrine may be associated with worse outcomes, including higher serum levels of creatinine 6
• The placement of a tunneled peritoneal drainage catheter has been shown to be safe and effective, with a low rate of adverse events 7