What is the recommended dose and administration of albumin (human albumin) after paracentesis?

Albumin Administration After Paracentesis

For large-volume paracentesis (>5 liters), albumin should be administered at a dose of 6-8 grams per liter of ascitic fluid removed to prevent paracentesis-induced circulatory dysfunction. 1, 2

Dosing Guidelines

Volume-Based Approach

• Large-volume paracentesis (>5 liters): 6-8 g albumin per liter of ascitic fluid removed 2, 1
• Small-volume paracentesis (<5 liters):
  • Some guidelines suggest synthetic plasma expanders may be sufficient 1
  • However, many experts recommend considering albumin even for smaller volumes to ensure safety 1

Standardized Dosing Protocol

A practical standardized approach that has been validated in clinical practice 3:

• 25 g albumin for 5-6 liters removed
• 50 g albumin for 7-10 liters removed
• 75 g albumin for >10 liters removed

Timing of Administration

• Albumin should be administered intravenously immediately after the paracentesis procedure is completed
• Some centers divide the dose, giving half immediately after paracentesis and half 6-8 hours later, though there is no strong evidence supporting this approach over a single administration

Rationale for Albumin Administration

Albumin administration after large-volume paracentesis has been shown to:

1. Prevent paracentesis-induced circulatory dysfunction (PICD) 2, 1
2. Reduce the risk of hyponatremia by 42% 1
3. Decrease mortality by 36% 1
4. Prevent renal impairment 2

PICD is characterized by an increase in plasma renin activity >50% of pre-treatment values 4-6 days after paracentesis and may develop in up to 80% of patients without volume expansion 1.

Alternative Approaches

Lower Albumin Dosing

Some studies have investigated using lower doses of albumin (4 g/L of ascitic fluid removed) with promising results 4, 5. However, these are smaller pilot studies, and the standard 6-8 g/L remains the recommended dose based on more robust evidence.

Alternative Volume Expanders

• Non-albumin plasma expanders (dextran, hydroxyethylstarch, gelatin) have been studied but are less effective than albumin in preventing PICD 1
• Vasoconstrictors:
  • Midodrine has been studied but was found to be less effective than albumin in preventing PICD 6, 7
  • Terlipressin may have some efficacy but is not currently available in the United States 2

Common Pitfalls and Caveats

1. Underestimating volume removed: Ensure accurate measurement of ascitic fluid volume to calculate the correct albumin dose
2. Delaying albumin administration: Albumin should be given immediately after paracentesis
3. Overlooking sodium restriction: Patients should maintain a low-sodium diet (≤5 g/day) even after paracentesis 1
4. Forgetting to restart diuretics: Diuretics should be restarted within 1-2 days after paracentesis to prevent rapid reaccumulation of ascites 1
5. Ignoring beta-blocker considerations: In patients with refractory ascites, non-selective beta-blockers may need to be suspended as they can increase the frequency of PICD 1

Special Considerations

• Cost concerns: Albumin is expensive, which has driven research into lower-dose protocols and alternatives. However, the clinical benefits of standard dosing (6-8 g/L) outweigh the cost considerations for most patients
• Patients with spontaneous bacterial peritonitis: These patients require a different albumin regimen (1.5 g/kg at diagnosis and 1 g/kg at day 3) 2
• Limiting paracentesis volume: Consider limiting single paracentesis sessions to <8 liters as the risk of PICD increases with larger volumes 1

By following these evidence-based guidelines for albumin administration after paracentesis, clinicians can minimize the risk of complications and improve outcomes in patients with cirrhotic ascites.