What is the recommended dose of albumin (human albumin) to administer during paracentesis?

From the Guidelines

The recommended dose of human albumin during paracentesis is 6-8 grams of albumin per liter of ascitic fluid removed when large-volume paracentesis (greater than 5 liters) is performed. This is based on the most recent and highest quality study available, which suggests that albumin infusion at a dose of 6-8 g/L of ascites removed is effective in preventing post-paracentesis circulatory dysfunction (PPCD) 1.

Key Points to Consider

• The albumin should be given during or immediately after the paracentesis procedure.
• For paracentesis with removal of less than 5 liters of fluid, albumin administration is generally not necessary unless the patient has severe hypoalbuminemia or renal dysfunction.
• The purpose of albumin administration during large-volume paracentesis is to prevent post-paracentesis circulatory dysfunction, which can lead to rapid reaccumulation of ascites, hepatorenal syndrome, and increased mortality.
• Albumin helps maintain intravascular volume and oncotic pressure by drawing fluid from the interstitial space into the bloodstream, counteracting the hemodynamic changes that occur when large volumes of ascitic fluid are removed.

Supporting Evidence

• A recent study published in 2021 in the journal Hepatology found that albumin infusion at a dose of 6-8 g/L of ascites removed was effective in preventing PPCD 1.
• Another study published in 2024 in the journal Gastroenterology found that albumin should be administered during paracentesis at a dose of 6–8 g/L regardless of the amount of ascites removed 1.
• The use of albumin in paracentesis has been consistently recommended in various guidelines, including those from the American Association for the Study of Liver Diseases and the International Ascites Club 1.

Administration Details

• The albumin can be administered as a 25% albumin solution at a dose of 25-50 mL (6.25-12.5 grams) for every liter of ascitic fluid removed.
• The albumin should be given during or immediately after the paracentesis procedure to maximize its effectiveness in preventing PPCD.

From the Research

Albumin Dosage in Paracentesis

The recommended dose of albumin to administer during paracentesis is based on the amount of ascitic fluid removed.

• According to the study 2, 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 3 used 6-8 g of albumin per liter of ascites drained, with a total of ≤8 L removed.
• The use of human albumin in patients with cirrhotic ascites undergoing paracentesis has been shown to reduce the odds of paracentesis-induced circulatory dysfunction (PICD) by 60% 4.

Administration Guidelines

The administration of albumin in paracentesis is guided by the following principles:

• Albumin should be used to prevent PICD, especially in patients with large-volume paracentesis 2, 4.
• The dose of albumin should be based on the amount of ascitic fluid removed, with higher doses used for larger volumes 2, 3.
• Albumin may be used in combination with other treatments, such as midodrine, to manage PICD 5.

Safety and Efficacy

The safety and efficacy of human albumin treatment in patients with cirrhotic ascites undergoing paracentesis have been evaluated in several studies.

• A systematic review and meta-analysis found that albumin use reduced the odds of PICD and hyponatremia, but did not reduce overall mortality, readmission rate, recurrence of ascites, or other complications 4.
• Another study found that the use of an order set to guide albumin dosing based on the amount of ascitic fluid removed resulted in a significant reduction in the amount of albumin given, with no difference in adverse effects 2.