What is the indication of albumin in ascites fluid?

From the Guidelines

Albumin infusion is indicated for patients with cirrhotic ascites who are undergoing large-volume paracentesis (removal of more than 5 liters of ascitic fluid) 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.

Implementation

To implement this recommendation:

• Administer 25% albumin solution intravenously
• Give 8 grams of albumin for every liter of ascitic fluid removed
• Infuse slowly over 2-4 hours following the paracentesis

This treatment helps prevent post-paracentesis circulatory dysfunction, which can lead to rapid re-accumulation of ascites and renal impairment. Albumin works by expanding plasma volume and improving cardiovascular function, thereby maintaining effective arterial blood volume after fluid removal. The use of albumin in this setting has been shown to reduce the incidence of post-paracentesis circulatory dysfunction, hyponatremia, and mortality 1.

Key Points

• Albumin infusion is not routinely recommended for smaller volume paracentesis or for other causes of ascites, as the risks and costs may outweigh the benefits
• The recommended dose of 8 g albumin/L of ascites removed is based on high-quality evidence and should be followed to minimize complications
• The use of albumin in this setting has been shown to improve outcomes, including reduced mortality and morbidity, and improved quality of life 1

From the Research

Indication of Albumin in Ascites Fluid

The indication of albumin in ascites fluid is to prevent paracentesis-induced circulatory dysfunction (PICD) in patients with cirrhosis undergoing large volume paracentesis.

• Albumin infusion is effective in preventing PICD, with a recommended dose of 8g of albumin per liter of ascites removed 2.
• However, studies have also shown that half doses of albumin (4g/L) can be effective in preventing PICD, which could support a significant cost reduction in the management of ascites in cirrhotic patients 2.
• The use of albumin in patients with cirrhotic ascites has been extensively studied, with results showing that it reduces the odds of PICD by 60% compared to other volume expanders 3.
• Albumin administration also improves survival in patients with spontaneous bacterial peritonitis, and can improve circulatory and renal function in patients with hepatorenal syndrome when used in combination with vasoconstrictor drugs 4, 5.

Dosage and Administration

• The dosage of albumin used in ascites fluid can vary, with some studies using a standardized dose of 25g, 50g, or 75g based on the amount of ascitic fluid removed 6.
• The administration of albumin can be guided by an order set to reduce the amount of albumin given and minimize adverse effects 6.
• Long-term administration of albumin may improve the diuretic response in selected patients with ascites 5.

Clinical Outcomes

• The use of albumin in ascites fluid has been shown to reduce the incidence of hyponatremia and PICD, but does not reduce overall mortality, readmission rate, recurrence of ascites, hepatic encephalopathy, or gastrointestinal bleeding 3.
• Albumin infusion can improve survival in patients with spontaneous bacterial peritonitis, and can improve circulatory and renal function in patients with hepatorenal syndrome when used in combination with vasoconstrictor drugs 4, 5.