Should albumin be given as a bolus or as a 24-hour infusion after paracentesis (peritoneal fluid removal)?

Albumin Administration After Paracentesis: Bolus vs. 24-Hour Infusion

Albumin should be administered as a bolus infusion rather than a 24-hour infusion after paracentesis for optimal prevention of paracentesis-induced circulatory dysfunction (PICD) and improved patient outcomes. 1

Evidence-Based Rationale

Recommended Administration Method

• The standard practice supported by clinical guidelines is to administer albumin as a bolus infusion after paracentesis, not as a 24-hour infusion 2, 1
• No guideline recommends extended 24-hour infusions of albumin after paracentesis
• The European Association for the Study of the Liver and American College of Chest Physicians recommend albumin administration at 8 g/L of ascites removed, typically given as a bolus infusion 1

Dosing Recommendations

• For large-volume paracentesis (>5 liters):

  • Administer albumin at 8 g/L of ascites removed 2, 1
  • Use 20% or 25% albumin solution 1

• For smaller-volume paracentesis (<5 liters):

  • Consider albumin administration in high-risk patients (those with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury) 1, 3
  • Use the same dosing (8 g/L of ascites removed) 1

Clinical Benefits of Albumin Administration

• Albumin infusion reduces the incidence of PICD by 61% compared to alternative treatments (OR = 0.39,95% CI 0.27-0.55) 2, 4
• Reduces risk of hyponatremia by 42% (OR = 0.58,95% CI 0.39-0.87) 2, 4
• Reduces mortality by 36% (OR = 0.64,95% CI 0.41-0.98) 2, 4
• Decreases incidence of hepatic encephalopathy, acute kidney injury, and in-hospital mortality in patients with acute-on-chronic liver failure 3

Practical Implementation

Volume-Based Albumin Dosing Algorithm

• 5-6 L removed: 25 g albumin 5
• 7-10 L removed: 50 g albumin 5

• 10 L removed: 75 g albumin 5

Important Considerations

• Limit paracentesis to less than 8 liters per session to minimize the risk of PICD 2, 1
• Complete the paracentesis procedure within 1-4 hours 1
• After paracentesis, have the patient lie on the opposite side for 2 hours if there is residual ascitic fluid leakage 1
• Diuretics can be safely reintroduced within 1-2 days after paracentesis 1

Special Populations

Patients with Acute-on-Chronic Liver Failure

• These patients are at higher risk of developing PICD even with modest-volume paracentesis (<5 L) 3
• Albumin administration (8 g/L) significantly reduces PICD incidence (30% vs 70%, p=0.001) and mortality (27.5% vs 62.5%, p=0.003) in this population 3

Historical Context

The efficacy of albumin administration after paracentesis was established in early studies, including a landmark 1988 randomized trial that demonstrated significant reductions in renal impairment and hyponatremia with albumin administration versus no albumin 6. This and subsequent research established the bolus administration method as the standard of care, with no evidence supporting prolonged 24-hour infusions.