What is the requirement for albumin (human albumin) infusion during ascitic paracentesis?

Albumin Requirements During Ascitic Paracentesis

Albumin should be administered at a dose of 8g per liter of ascitic fluid removed during large-volume paracentesis (>5L) to prevent post-paracentesis circulatory dysfunction. 1

Rationale for Albumin Administration

Albumin infusion during paracentesis serves to prevent paracentesis-induced circulatory dysfunction (PICD), a serious complication that can lead to:

• Increased rate of recurrent ascites
• Development of hepatorenal syndrome
• Hyponatremia
• Reduced survival 2

PICD occurs when large volumes of ascitic fluid are removed without adequate plasma volume expansion, leading to hemodynamic disturbances and activation of vasoactive systems.

Evidence-Based Recommendations

Volume-Based Recommendations:

• Large-volume paracentesis (>5L): Albumin administration at 8g per liter of ascitic fluid removed is strongly recommended 1, 2
• Paracentesis <5L:
  • Generally, the risk of PICD is low 2
  • However, albumin should still be considered, especially in patients with acute-on-chronic liver failure (ACLF) 1, 3

Supporting Evidence:

A meta-analysis of 17 randomized studies (1,225 patients) demonstrated that albumin infusion:

• Reduced the odds of PICD by 61% (OR = 0.39,95% CI 0.27–0.55)
• Reduced hyponatremia by 42% (OR = 0.58,95% CI 0.39–0.87)
• Reduced mortality by 36% (OR = 0.64,95% CI 0.41–0.98) 2, 4

Albumin has proven superior to alternative plasma expanders (dextran, gelatin, hydroxyethyl starch, hypertonic saline) in preventing PICD 4.

Special Considerations

Acute-on-Chronic Liver Failure (ACLF):

Patients with ACLF require special attention:

• PICD can develop even with modest-volume paracentesis (<5L) in ACLF patients
• A randomized study showed that albumin infusion in ACLF patients undergoing <5L paracentesis:
  • Decreased PICD incidence (30% vs 70% without albumin)
  • Reduced complications including hepatic encephalopathy, hyponatremia, and acute kidney injury
  • Lowered in-hospital mortality (27.5% vs 62.5% without albumin) 3

Practical Implementation:

A standardized approach to albumin dosing has been shown to be effective:

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

This approach resulted in an average albumin dose of 6.5g/L (compared to 8.3g/L in non-standardized dosing) without differences in adverse outcomes 5.

Procedural Considerations

• Complete drainage to dryness in a single session is recommended
• Paracentesis should be performed under strict sterile conditions
• Ultrasound guidance should be used when available
• Drains should not be left in overnight to reduce infection risk
• Paracentesis should be limited to less than 8 liters per session to minimize PICD risk 1
• Diuretics should be reintroduced within 1-2 days after paracentesis 1

Common Pitfalls to Avoid

1. Underestimating PICD risk in smaller volume paracentesis: While the risk is lower with <5L removal, patients with ACLF still benefit from albumin administration 3

2. Inadequate monitoring: Patients should be monitored for hypotension during and after paracentesis, as fatal hypotension has been reported in the first 24 hours 1

3. Repeated low-volume paracentesis: This approach offers no additional benefits and carries a higher risk of procedure-related complications 1

4. Overlooking the need for albumin in specific populations: Even with smaller volume paracentesis, certain high-risk patients (those with ACLF, poor renal function, or severe liver dysfunction) may benefit from albumin administration 1, 3