What is the formula for replacing albumin (human albumin) after performing a paracentesis (percutaneous abdominal paracentesis)?

From the Guidelines

The recommended formula for albumin replacement after paracentesis is to administer 8 grams of intravenous human albumin for every liter of ascitic fluid removed when the volume exceeds 5 liters. For paracentesis with removal of less than 5 liters, albumin replacement is generally not required unless the patient has severe liver disease or is hemodynamically unstable. The albumin should be administered during or immediately after the procedure. This recommendation is based on the most recent and highest quality study, which found that albumin infusion after paracentesis is the most effective therapy in preventing post-paracentesis circulatory dysfunction (PICD) 1. The use of albumin has been shown to reduce the odds of PICD by 61% and decrease the incidence of hyponatremia and mortality compared to alternative plasma expanders 1.

Key Points

• Albumin replacement is recommended for paracentesis with removal of more than 5 liters of ascitic fluid.
• The recommended dose is 8 grams of intravenous human albumin for every liter of ascitic fluid removed.
• Albumin should be administered during or immediately after the procedure.
• For paracentesis with removal of less than 5 liters, albumin replacement is generally not required unless the patient has severe liver disease or is hemodynamically unstable.

Rationale

The rationale for albumin replacement is to prevent post-paracentesis circulatory dysfunction, which can lead to rapid reaccumulation of ascites, hepatorenal syndrome, and increased mortality. Albumin works by maintaining plasma oncotic pressure and binding various substances including bilirubin, fatty acids, and drugs, while also providing antioxidant effects and improving immune function in cirrhotic patients. The use of albumin has been shown to be more effective than alternative plasma expanders in preventing PICD and reducing the incidence of hyponatremia and mortality 1.

Practical Considerations

For practical purposes, the recommended formula typically translates to 50 mL of 25% albumin (12.5 grams) or 100 mL of 12.5% albumin for every 2-3 liters of ascitic fluid removed. However, the exact dose and administration schedule may vary depending on the individual patient's needs and the specific clinical context. It is essential to follow the recommended guidelines and consult with a healthcare professional to determine the best course of treatment for each patient.

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 formula for replacing albumin after performing a paracentesis is not explicitly stated in the FDA drug label. However, it is mentioned that albumin infusion may be required to support the blood volume in cases where removal of ascitic fluid causes changes in cardiovascular function or hypovolemic shock.

• 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 2.

From the Research

Formula for Replacing Albumin after Paracentesis

The formula for replacing albumin after performing a paracentesis is not strictly defined as a single formula but rather as guidelines based on the volume of ascitic fluid removed.

• According to the study 3, albumin doses were standardized to 25 g for 5-6 L removed, 50 g for 7-10 L, and 75 g for more than 10 L.
• Another study 4 suggests that salt-free human albumin should be the plasma expander of choice, especially if at least 8 liters are evacuated.
• The 2021 AASLD Practice Guidance, as assessed in the study 5, recommends albumin infusion when removing ≥5 L of ascites to prevent post-paracentesis circulatory dysfunction.

Key Considerations

• The use of albumin infusion reduces the incidence of postparacentesis circulatory dysfunction and hyponatremia, as shown in studies 6 and 7.
• The optimal criteria and scenarios for initiating albumin infusion subsequent to therapeutic paracentesis are subject to ongoing research, with some studies suggesting a potential benefit even at lower volumes of ascites removal 5.
• Albumin does not appear to reduce overall mortality, readmission rate, recurrence of ascites, mean arterial pressure, incidence of renal impairment, hepatic encephalopathy, and gastrointestinal bleeding, as indicated in study 7.

Volume-Based Guidelines

• For removal of 5-6 L of ascitic fluid, 25 g of albumin is recommended 3.
• For removal of 7-10 L, 50 g of albumin is suggested 3.
• For removal of more than 10 L, 75 g of albumin is advised 3.
• Removal of at least 8 liters may benefit from salt-free human albumin as the plasma expander of choice 4.
• Infusion at the threshold of 5 L of ascites removal may reduce serum creatinine levels and increase serum sodium levels 5.