Albumin Administration After Paracentesis
Albumin should be administered after paracentesis when more than 5 liters of ascitic fluid is removed, at a dose of 6-8 g of albumin per liter of fluid removed. 1
Paracentesis Volume and Albumin Requirements
Large Volume Paracentesis (>5 L)
- Definite albumin requirement: Strong evidence supports albumin administration for paracentesis >5 L 1
- Recommended dose: 6-8 g of albumin per liter of ascitic fluid removed 1
- Example calculation: For 8 L removal = 8 L × 8 g/L = 64 g albumin (equivalent to 320 mL of 20% albumin solution or 256 mL of 25% albumin solution) 2
Small Volume Paracentesis (<5 L)
- Conditional albumin requirement: Consider albumin administration in patients with:
- Acute-on-chronic liver failure (ACLF)
- High risk of post-paracentesis acute kidney injury 1
- Same dosing of 6-8 g/L if administered
Clinical Rationale for Albumin Administration
Albumin administration prevents post-paracentesis circulatory dysfunction (PPCD), which is associated with:
- Increased recurrence of ascites
- Development of hepatorenal syndrome
- Hyponatremia
- Reduced survival 1
A meta-analysis of 17 randomized studies (1,225 patients) showed albumin infusion reduces:
- Risk of PPCD by 61% (OR = 0.39,95% CI 0.27-0.55)
- Hyponatremia by 42% (OR = 0.58,95% CI 0.39-0.87)
- Mortality by 36% (OR = 0.64,95% CI 0.41-0.98) 1
Volume Limitations and Special Considerations
- Maximum recommended volume: Limit ascites removal to <8 L per session when possible, as risk of PPCD increases with >8 L removed in one session 1
- Administration timing: Albumin should be infused after paracentesis is completed 2
- Infusion rate: Administer albumin slowly to prevent potential cardiac overload, especially in patients with pre-existing cardiomyopathy 1, 2
Alternative Plasma Expanders
Non-albumin plasma expanders (dextran, hydroxyethyl starch, gelatin, hypertonic saline) are less effective than albumin in preventing PPCD 1, 3.
Special Situations
- Some evidence suggests half-dose albumin (4 g/L) might be effective in selected patients with low severity cirrhosis (MELD score 16-17), but this approach is not currently recommended in guidelines 4
- For patients with spontaneous bacterial peritonitis, a different albumin dosing regimen is recommended (1.5 g/kg on day 1 and 1 g/kg on day 3) 1
Clinical Pitfalls to Avoid
- Don't underestimate fluid volume: Accurately measure removed ascitic fluid to calculate proper albumin dose
- Don't skip albumin for >5 L removal: The cost of albumin should not deter its use when indicated
- Don't remove excessive volumes: Consider limiting single-session paracentesis to <8 L to reduce PPCD risk
- Don't administer too rapidly: Infuse albumin slowly to prevent circulatory overload